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. Maternal Child Nursing Care - Chapter
17: Labor and Birth Complications
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? a. Urine output of 160 mL in 4 hours b. Deep tendon reflexes 2+ and no clonus c. Respiratory rate of 16 breaths/min d. Serum magnesium level of 10 mg/dL - ✔✔ANS: D The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings. A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: a. stimulate fetal surfactant production. b. reduce maternal and fetal tachycardia associated with ritodrine administration. c. suppress uterine contractions.
d. maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy. - ✔✔ANS: A Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? a. Estriol is not found in maternal saliva. b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. c. Fetal fibronectin is present in vaginal secretions. d. The cervix is effacing and dilated to 2 cm. - ✔✔ANS: D Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor such as cervical changes.
c. Preterm labor and birth d. Postterm gestation - ✔✔ANS: D Postterm gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births. A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Arrest of active phase d. Protracted descent - ✔✔ANS: C With an arrest of the active phase, the progress of labor has stopped. This patient has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.
In evaluating the effectiveness of oxytocin induction, the nurse would expect: a. contractions lasting 80 to 90 seconds, 2 to 3 minutes apart. b. the intensity of contractions to be at least 110 to 130 mm Hg. c. labor to progress at least 2 cm/hr dilation. d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation. - ✔✔ANS: A The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 80 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min. A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority? a. Placing the woman in the knee-chest position. b. Covering the cord in sterile gauze soaked in saline. c. Preparing the woman for a cesarean birth. d. Starting oxygen by face mask. - ✔✔ANS: A The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord
This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation. The patient's needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the patient experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the patient's membranes have ruptured. Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance: a. the terms preterm birth and low birth weight can be used interchangeably. b. preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. c. low birth weight is anything below 3.7 lbs. d. in the United States early in this century, preterm birth accounted for 18% to 20% of all births. - ✔✔ANS: B Before 20 weeks, it is not viable (miscarriage); after 37 weeks, it can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation ( weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything less than 2500 g, or about 5.5 lbs. In 2003 the preterm birth rate in the United States was 12.3%, but it is increasing in frequency.
With regard to the care management of preterm labor, nurses should be aware that: a. all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms. b. Braxton Hicks contractions often signal the onset of preterm labor. c. preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d. the diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change. - ✔✔ANS: D Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor. As relates to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: a. the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. b. there are no important maternal (as opposed to fetal) contraindications.
a. midplane contracture of the pelvis. b. compromised bearing-down efforts as a result of pain medication. c. disproportion of the pelvis. d. low-lying placenta. - ✔✔ANS: C The least common cause of dystocia is disproportion of the pelvis. Nurses should be aware that the induction of labor: a. can be achieved by external and internal version techniques. b. is also known as a trial of labor (TOL). c. is almost always done for medical reasons. d. is rated for viability by a Bishop score. - ✔✔ANS: D Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons. While caring for the patient who requires an induction of labor, the nurse should be cognizant that: a. ripening the cervix usually results in a decreased success rate for induction.
b. labor sometimes can be induced with balloon catheters or laminaria tents. c. oxytocin is less expensive than prostaglandins and more effective but creates greater health risks. d. amniotomy can be used to make the cervix more favorable for labor. - ✔✔ANS: B Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe. In planning for home care of a woman with preterm labor, which concern must the nurse address? a. Nursing assessments will be different from those done in the hospital setting. b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers will be necessary. - ✔✔ANS: C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged after birth recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many
c. is a modern management term to cover up the negative connotations of forceps-assisted birth. d. uses vacuum cups. - ✔✔ANS: A Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation. The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births. a. Viral b. Periodontal c. Cervical d. Urinary tract - ✔✔ANS: A The infections that increase the risk of preterm labor and birth are all bacterial. They include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, it is important for the patient to participate in early, continual, and comprehensive prenatal care. Evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene
to prevent infection. Cervical infections of a bacterial nature have been linked to preterm labor and birth. The presence of urinary tract infections increases the risk of preterm labor and birth. The standard of care for obstetrics dictates that an internal version may 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 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. The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is: a. a gravida 3 who has had two low-segment transverse cesarean births. b. a gravida 2 who had a low-segment vertical incision for delivery of a 10-lb infant. c. a gravida 5 who had two vaginal births and two cesarean births.
A mother who is exhausted may be unable to assist with the expulsion of the fetus. The patient with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum extraction. The priority nursing intervention after an amniotomy should be to: a. assess the color of the amniotic fluid. b. change the patient's gown. c. estimate the amount of amniotic fluid. d. assess the fetal heart rate. - ✔✔ANS: D The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Secondary to FHR assessment, amniotic fluid amount, color, odor, and consistency is assessed. Dry clothing is important for patient comfort; however, it is not the top priority. 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
Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse's priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of Pitocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labor progression is the standard of care for all labor patients. 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 infant's scalp. d. measure the circumference of the infant's head. - ✔✔ANS: A The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would put the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment. 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
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 These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks' completed gestation.
