Chapter 27: Intrapartum Complications My Nursing Test Banks

Chapter 27: Intrapartum Complications

MULTIPLE CHOICE

1. Which pelvic shape is most conducive to vaginal labor and birth?

a.

Android

b.

Gynecoid

c.

Platypelloid

d.

Anthropoid

ANS: B

The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch. The prognosis for a vaginal birth is good. Only 30% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 574

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

2. Which action by the nurse prevents infection in the labor and birth area?

a.

Using clean techniques for all procedures

b.

Keeping underpads and linens as dry as possible

c.

Cleaning secretions from the vaginal area by using a back to front motion

d.

Performing vaginal examinations every hour while the client is in active labor

ANS: B

Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.

PTS: 1 DIF: Cognitive Level: Application REF: 576

OBJ:Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

3. A pregnant client with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicate a potential infection?

a.

Fetal heart rate, 150 beats/min

b.

Maternal temperature, 99 F

c.

Cloudy amniotic fluid, with strong odor

d.

Lowered maternal pulse and decreased respiratory rates

ANS: C

Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/min is often the first sign of intrauterine infection. A temperature of 100.4 F or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 576

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

4. A client in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will be prescribed for at-home continuation of the tocolytic effect?

a.

Buccal oxytocin (Pitocin)

b.

Terbutaline sulfate (Brethine)

c.

Calcium gluconate (Calgonate)

d.

Magnesium sulfate

ANS: B

The client receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. Pitocin increases the strength of contractions and is used to augment or stimulate labor. Buccal Pitocin dosing is uncontrollable. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.

PTS: 1 DIF: Cognitive Level: Application REF: 585

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

5. A client with polyhydramnios was admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless, but the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next?

a.

Perform Leopold maneuvers.

b.

Perform a vaginal examination.

c.

Apply warm saline soaks to the vagina.

d.

Place the client in a high Fowler position.

ANS: B

A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.

PTS: 1 DIF: Cognitive Level: Application REF: 591

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity

6. Which technique is least effective for the client with persistent occiput posterior position?

a.

Squatting

b.

Lying supine and relaxing

c.

Sitting or kneeling, leaning forward with support

d.

Rocking the pelvis back and forth while on hands and knees

ANS: B

Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

PTS: 1 DIF: Cognitive Level: Application REF: 572

OBJ:Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

7. Birth for the nulliparous client with a fetus in a breech presentation is usually:

a.

cesarean section.

b.

vaginal birth.

c.

vacuumed extraction.

d.

forceps-assisted birth.

ANS: A

Birth for the nulliparous client with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.

PTS: 1 DIF: Cognitive Level: Understanding REF: 572

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

8. Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?

a.

A primigravida who is 17 years old

b.

A 22-year-old multiparous client with ruptured membranes

c.

A primigravida who has requested no analgesia during her labor

d.

A multiparous client at 39 weeks of gestation who is expecting twins

ANS: D

Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this clients uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.

PTS: 1 DIF: Cognitive Level: Analysis REF: 569

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

9. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?

a.

Incomplete uterine relaxation

b.

Maternal fatigue and exhaustion

c.

Maternal sedation with narcotics

d.

Administration of tocolytic drugs

ANS: A

A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.

PTS: 1 DIF: Cognitive Level: Understanding REF: 573

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

10. After a birth complicated by a shoulder dystocia, the infants Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:

a.

palpate the infants clavicles.

b.

encourage the parents to hold the infant.

c.

perform a complete newborn assessment.

d.

give supplemental oxygen with a small face mask.

ANS: A

Because of the shoulder dystocia, the infants clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.

PTS: 1 DIF: Cognitive Level: Understanding REF: 570, 571

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

11. A laboring client in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?

a.

You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger.

b.

Let me take off the monitor belts and help you get into a more comfortable position.

c.

You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain.

d.

I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.

ANS: D

Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the client cope with the situation, no matter at what stage. It is important to get her into a more comfortable position, but fetal monitoring should continue. Breathing will not decrease the pain.

PTS: 1 DIF: Cognitive Level: Application REF: 570

OBJ:Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

12. Which nursing action should be initiated first when there is evidence of prolapsed cord?

a.

Notify the health care provider.

b.

Apply a scalp electrode.

c.

Prepare the mother for an emergency cesarean birth.

d.

Reposition the mother with her hips higher than her head.

ANS: D

The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority.

PTS: 1 DIF: Cognitive Level: Application REF: 591

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity

13. A client who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurses priority action?

a.

Notify the health care provider promptly.

b.

Observe for abnormally high uterine resting tone.

c.

Decrease the rate of nonadditive intravenous fluid.

d.

Reposition the client with her hips slightly elevated.

ANS: A

Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the client at high risk for uterine rupture. The client is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the client with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.

PTS: 1 DIF: Cognitive Level: Application REF: 592

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity

14. Which factor should alert the nurse to the potential for a prolapsed umbilical cord?

a.

Oligohydramnios

b.

Pregnancy at 38 weeks of gestation

c.

Presenting part at a station of 3

d.

Meconium-stained amniotic fluid

ANS: C

Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the client at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the client at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.

PTS: 1 DIF: Cognitive Level: Understanding REF: 590

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

15. The fetus in a breech presentation is often born by cesarean birth because:

a.

the buttocks are much larger than the head.

b.

compression of the umbilical cord is more likely.

c.

internal rotation cannot occur if the fetus is breech.

d.

postpartum hemorrhage is more likely if the client delivers vaginally.

ANS: B

After the fetal legs and trunk emerge from the clients vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.

PTS: 1 DIF: Cognitive Level: Understanding REF: 590

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

16. A client who is 32 weeks pregnant telephones the nurse at her obstetricians office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is:

a.

You should come into the office and let the doctor check you.

b.

Acetaminophen is acceptable during pregnancy. You should not take aspirin, however.

c.

Back pain is common at this time during pregnancy because you tend to stand with a sway back.

d.

Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.

ANS: A

A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The client needs to be assessed for preterm labor before providing pain relief.

PTS: 1 DIF: Cognitive Level: Application REF: 580

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity

17. Which is (are) the priority nursing assessment(s) for the client having tocolytic therapy with terbutaline (Brethine)?

a.

Intake and output

b.

Maternal blood glucose level

c.

Internal temperature and odor of amniotic fluid

d.

Fetal heart rate, maternal pulse, and blood pressure

ANS: D

All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured, but these are not relevant to the medication.

PTS: 1 DIF: Cognitive Level: Application REF: 576

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

18. Which assessment finding indicates uterine rupture?

a.

Fetal tachycardia occurs.

b.

The client becomes dyspneic.

c.

Labor progresses unusually quickly.

d.

Contractions abruptly stop during labor.

ANS: D

A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.

PTS: 1 DIF: Cognitive Level: Understanding REF: 582

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

19. Which intervention should be incorporated in a plan of care for a labor client who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam3 cm, 80% effaced, and 0 station presenting part vertex.

a.

Augmentation of labor with oxytocin (Pitocin)

b.

AROM

c.

Performing a vaginal exam to denote progress

d.

Preparing the client for epidural administration as ordered by the physician

ANS: D

The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore, augmentation would not be advised as this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.

PTS: 1 DIF: Cognitive Level: Analysis REF: 570

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

20. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken by the nurse in response to this request?

a.

Put pressure on the fundus.

b.

Ask the physician if he or she would like you to prepare for a surgical method of birth.

c.

Tell the client not to push until you prepare vacuum extraction device for physician.

d.

Reposition the client to facilitate birth.

ANS: B

In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it can cause additional problems. Vacuum extraction will not help solve this birth issue and may lead to further complications. Repositioning of the client may not be effective to relieve this condition and facilitate birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 570, 571

OBJ:Nursing Process Step: Planning

MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

21. A pregnant client who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered an fFN (fetal fibronectin) test. Which instructions should be given to the client related to this clinical test?

a.

Client must be NPO prior to testing.

b.

Blood work will be drawn every week to help confirm the start of preterm labor.

c.

Client should refrain from sexual activity prior to testing.

d.

A urine specimen will be collected for testing.

ANS: C

Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.

PTS: 1 DIF: Cognitive Level: Application REF: 581

OBJ:Nursing Process Step: Planning

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

22. An obstetric client has been identified as being high risk and so has had activities restrictions (placed on bed rest) placed on her until the end of the pregnancy. Currently, she is at 32 weeks gestation and has two other children at home, ages 3 and 6. The clients husband works at home. A nursing diagnosis of Impaired home maintenance is noted. Which statement potentially identifies a long-term goal?

a.

The client and husband will be able to adapt their schedules accordingly to meet activities of daily living until the clients next scheduled antepartum visit the following week.

b.

The client and husband will hire a nanny to act as an additional caregiver for the next month.

c.

The client will continue to take care of her children at home, taking frequent rest periods.

d.

The client and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.

ANS: D

A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified time frame. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the client to take care of her children at home with rest period because the client will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications.

PTS: 1 DIF: Cognitive Level: Analysis REF: 580

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

23. A labor client has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, what birth method is available?

a.

Vaginal birth with vacuum extraction

b.

Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions

c.

Cesarean section

d.

Insertion of Foley catheter into empty bladder to provide more room for fetal descent

ANS: C

The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the client should be prepped for a cesarean section.

PTS: 1 DIF: Cognitive Level: Analysis REF: 570

OBJ:Nursing Process Step: Evaluation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency

24. A client is diagnosed with anaphylactoid syndrome. Which therapeutic intervention does the nurse suspect will be included in the plan of care?

a.

Normal amniotic fluid

b.

Initiation of CPR and other life support measures

c.

Respiratory treatments with nebulizers

d.

Internal fetal monitoring

ANS: B

Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 593

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency

25. A 20-year-old gravida 1, para 0, is determined to be at 42 weeks gestation on admission to the labor and birth unit. The client is not in labor at the current time but has been sent over by her physician to be admitted for the induction of labor. The client indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the clients request?

a.

There is no way to tell if any complications would arise. Because the client is not presenting with any problems, the nurse should call the health care provider and inform her or him of the clients decision to go home and wait.

b.

Inform the client that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting.

c.

Tell the client that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the client will be sent home.

d.

Tell the client that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physicians directions.

ANS: B

The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the client wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore, it is best for the client to remain in a supervised clinical setting. Indicating that the client could possibly go home would place the client at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks.

PTS: 1 DIF: Cognitive Level: Analysis REF: 590

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency

26. Which presentation is least likely to occur with a hypotonic labor pattern?

a.

Prolonged labor duration

b.

Fetal distress

c.

Maternal comfort during labor

d.

Irregular labor contraction pattern

ANS: B

A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and clients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure.

PTS: 1 DIF: Cognitive Level: Application REF: 569

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

27. Which finding by the nurse on a vaginal exam would be a concern if a spontaneous rupture of the membranes occurred?

a.

Cephalic presentation

b.

Left occiput position

c.

Dilation 2 cm

d.

Presenting part at 3 station

ANS: D

If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.

PTS: 1 DIF: Cognitive Level: Analysis REF: 590

OBJ:Nursing Process Step: Analysis

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

28. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes?

a.

Apply oxygen at 8 to 10 L/min.

b.

Stop the Pitocin infusion.

c.

Position the client in the knee-chest position.

d.

Increase the main line infusion to 150 mL/hr.

ANS: C

A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.

PTS: 1 DIF: Cognitive Level: Application REF: 591

OBJ:Nursing Process Step: Analysis

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

29. When increasing the IV infusion rate of terbutaline (Brethine) 0.01 mg/min every 30 minutes, the nurse knows to stop increasing the rate when the:

a.

maximum dose of 0.1 mg/min is reached.

b.

systolic blood pressure falls below 110 mm Hg.

c.

contractions are less than two in a 10-minute period.

d.

maternal heart rate remains over 120 beats/min.

ANS: D

The infusion rate is not increased or may be decreased if the maternal pulse rate remains over 120 beats/min (bpm). A maximum dose of 0.1 mg is above the recommended maximum rate, systolic blood pressure below 110 mm Hg may be a normal finding for this client, and the medication should continue to be increased until the maximum level is reached or contractions stop.

PTS: 1 DIF: Cognitive Level: Application REF: 584

OBJ:Nursing Process Step: Analysis

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

30. Which finding would indicate an adverse response to terbutaline (Brethine)?

a.

Fetal heart rate (FHR) of 134 bpm

b.

Heart rate of 122 bpm

c.

Two episodes of diarrhea

d.

Fasting blood glucose level of 100 mg/dL

ANS: B

Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.

PTS: 1 DIF: Cognitive Level: Analysis REF: 584

OBJ:Nursing Process Step: Assessment

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

31. A dose of dexamethasone 12 mg was administered to a client in preterm labor at 8:30 AM on March 12. The nurse knows that the next dose must be scheduled for:

a.

2:30 PM on March 12.

b.

8:30 PM on March 12.

c.

8:30 AM on March 13.

d.

2:30 PM on March 13.

ANS: C

The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 2:30 PM on March 12, 8:30 PM on March 12, and 2:30 PM on March 13 do not fall within this recommendation.

PTS: 1 DIF: Cognitive Level: Application REF: 586

OBJ:Nursing Process Step: Implementation

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

32. When reviewing the prenatal record of a client at 42 weeks gestation, the nurse recognizes that induction of labor is indicated based on the finding of:

a.

reduced amniotic fluid volume.

b.

cervix 2 cm at last prenatal visit.

c.

fundal height measured at the xyphoid process.

d.

1-pound weight gain at each of the last two weekly visits.

ANS: A

Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-pound weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 589

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

33. Which assessment finding in the postpartum client following a uterine inversion indicates normovolemia?

a.

Blood pressure of 100/60 mm Hg

b.

Urine output >30 mL/hr

c.

Rebound skin turgor <5 seconds

d.

Pulse rate <120 beats/min

ANS: B

In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hr; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/min may be indications of hypovolemia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 593

OBJ:Nursing Process Step: Assessment

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

34. Which assessment finding indicates a complication in the client attempting a vaginal birth after cesarean (VBAC)?

a.

Complaint of pain between the scapulae

b.

Change in fetal baseline from 128 to 132 bpm

c.

Contractions every 3 minutes lasting 70 seconds

d.

Pain level of 6 on scale of 0 to 10 during acme of contraction

ANS: A

A client attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 592

OBJ:Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

35. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurses next action?

a.

Palpate the patients bladder for fullness.

b.

Contact the health care provider for a prescription to augment the labor.

c.

Obtain an order for an internal pressure catheter.

d.

Reassure the patient that she is making adequate progress.

ANS: A

The fetal presenting part is expected to descend at a minimal rate of 1 cm/hr in the nullipara and 2 cm/hr in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.

PTS: 1 DIF: Cognitive Level: Synthesis REF: 575

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

MULTIPLE RESPONSE

36. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.)

a.

Administration of oxygen via face mask at 8 to 10 L/min

b.

Maternal change of position to knee-chest

c.

Administration of tocolytic agent

d.

Administration of oxytocin (Pitocin)

e.

Vaginal elevation

f.

Insertion of cord back into vaginal area

ANS: A, B, C, E

Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 591

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency

37. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.)

a.

Increased risk for placenta previa

b.

Painful uterine contractions

c.

Increased resting tone

d.

Uterine vasodilation

e.

Increased uterine pressure

f.

Effective uterine contraction

ANS: B, C, E

Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus, there is an increased risk for placental abruption as compared with placenta previa, which is based on malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor.

PTS: 1 DIF: Cognitive Level: Application REF: 569

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

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