Question 1

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?

Accepted Answer

The nurse should use a sterile glove during vaginal examination in the presence of ruptured membranes to prevent infection. Use of nonsterile gloves and instruments during vaginal examinations increases the risk of infection in the laboring client or fetus (eg, chorioamnionitis). (Option A) A nitrazine pH test strip inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal fluid, which is acidic. A blue-green, blue-gray, or deep blue color indicates a positive result and probable rupture of membranes. A yellow, olive-yellow, or olive green color indicates a negative result and suggests that membranes are intact. (Option C) Leopold maneuvers help determine fetal presentation and involve systematic palpation of the client's abdomen. These maneuvers assist the nurse in locating the fetal back for optimal placement of the ultrasound transducer for external fetal heart monitoring. (Option D) Hospital policy, provider preference, and the client risk profile will dictate appropriate oral intake during labor. However, there is no evidence to support NPO status of low-risk laboring clients, and most clients benefit from hydration provided by oral clear liquids during labor. Educational objective: Vaginal examinations of the laboring client with ruptured membranes should be performed using a sterile glove to decrease the risk of infection (eg, chorioamnionitis) to the client and fetus. Other labor admission interventions include application of external fetal monitoring and performance of a nitrazine pH test to determine if membranes have ruptured.

Question 2

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply.

Accepted Answer

Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option A) Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option B) Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option D) Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained (Option C) Artificial rupture of membranes (AROM), or amniotomy, is performed to augment labor or assess amniotic fluid in clients who are at term gestation. For clients in PTL, the goal is to prolong pregnancy if possible. Therefore, AROM is contraindicated. (Option E) Clients with suspected PTL should be placed on continuous fetal monitoring to assess for increasing frequency and duration of contractions and to evaluate fetal tolerance of labor. Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion. Educational objective: Preterm labor is progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate several interventions, including administration of IM antenatal glucocorticoids, antibiotics, and IV magnesium sulfate.

Question 3

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client?

Accepted Answer

Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive. If GBS status is unknown, antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks (Option A). (Option B) Part of the client's assessment includes evaluation of the uterine contraction pattern. However, the client and newborn are at risk for infection due to prolonged rupture of membranes and unknown GBS status, so antibiotic administration is the priority. (Option C) A urine specimen is often collected to evaluate for proteinuria in clients with elevated blood pressure or to assess for urinary tract infection in symptomatic clients. Urine specimen collection is not the priority for this client. (Option D) Vaginal examinations should be limited in the presence of ruptured membranes. Multiple vaginal examinations in such a client correlate with an increased risk for infection (eg, chorioamnionitis). Educational objective: Group B Streptococcus (GBS) infection can be transmitted to the newborn during labor and birth and cause serious complications. Indications for prophylactic antibiotics during labor include maternal GBS-positive status or unknown GBS status with fever ≥100.4 F (38 C), preterm gestation, and/or prolonged rupture of membranes.

Question 4

The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain?

Accepted Answer

11ecbb05_cc09_fdc9_b433_31e49dec8cf4_MD0009_00 Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg, blood products, intensive care unit) is recommended for clients with placenta accreta. The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary (Option D). (Option A) Previous cesarean birth is a risk factor for placenta accreta. Knowing the client's medical/surgical history is important but is not prioritized over the client's readiness for a blood transfusion. (Option B) A hysterectomy during cesarean birth with the placenta left in place may be required to reduce blood loss. The client should understand the implications of the procedure (ie, no future childbearing), but this is not a priority over ensuring readiness for a potential blood transfusion. (Option C) Metal and, occasionally, contact lenses should be removed prior to surgery to protect the client from injury, but this is not a priority over IV access and blood product availability. Educational objective: Placenta accreta occurs when the placenta adheres abnormally to the myometrium; attempted separation can result in life-threatening hemorrhage. Priority concerns include presence of at least two large-bore IVs and available blood products should hemorrhage occur.

Question 5

The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action?

Accepted Answer

11ecbb05_cc05_1bba_b433_594e837d441e_MD0009_00 The nurse is most likely palpating the diamond-shaped anterior fontanelle of the fetal head, which is in cephalic (ie, head down) presentation. Therefore, the nurse should document the fetal presentation as cephalic. The posterior fontanelle is triangular and separated from the anterior fontanelle by the sagittal suture. By identifying the location of these fetal skull landmarks, an experienced examiner can determine the fetal head position, or the direction the occiput is facing. (Option A) With breech presentation, the fetal buttocks, legs, or feet may be palpated. Fetal buttocks do not feel as round, smooth, or firm as the head during vaginal examination. Although the anus could be mistaken for a fontanelle, the anal sphincter feels firmer to palpation than a fontanelle and is circular, rather than triangular or diamond shaped. (Option C) A prolapsed cord would feel soft and rubbery on palpation and may be pulsating. If the cord is prolapsed, an emergency cesarean delivery is usually required. (Option D) Palpating the anterior fontanelle should reassure the nurse that the fetus is in a cephalic presentation, so there is no indication for informing the health care provider. Educational objective: Fetal head position can be determined by the sutures and fontanelles (eg, diamond-shaped anterior fontanelle) of the fetal skull.

Question 6

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action?

Accepted Answer

11ecbb05_cc05_69db_b433_0f6d81fb7d59_MD0009_00 The period of active labor from 8-10 cm dilation (ie, "transition") is often the most emotionally challenging phase of labor, marked by increased maternal anxiety. A mixture of mucus and pink/dark brown blood ("bloody show") is commonly observed during transition. Nursing priorities include providing emotional support and encouragement, and coaching the client in breathing techniques (Option D). (Option A) Meperidine (Demerol) is an opioid occasionally prescribed for analgesia during early labor. It has a rapid onset (5 minutes) when given IV, and a duration of 2-3 hours. However, it should be avoided within 1-4 hours of birth due to the potential for neonatal respiratory depression. (Option B) The second stage of labor begins once complete dilation (10 cm) is achieved. Clients may feel the urge to push (Ferguson reflex) prior to complete dilation if the fetal head is low in the pelvis. However, pushing should be delayed until complete dilation is achieved to avoid cervical swelling and/or cervical lacerations. (Option C) Although lithotomy positioning may be more convenient for the birth attendant, upright or lateral positions encourage fetal rotation and descent, increase client comfort, and decrease the risk of perineal trauma. This client has not yet reached complete dilation and should be allowed to move freely. Educational objective: The period of active labor from 8-10 cm dilation (ie, "transition") can be emotionally challenging for laboring clients. Signs of near-complete dilation include bloody show and the urge to push. Clients should be coached in breathing techniques and should avoid pushing until fully dilated to prevent cervical trauma.

Question 7

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply.

Accepted Answer

Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions (Option A). Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin (Option D). Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. Uterine tachysystole (ie, >5 contractions in 10 minutes) (Option E) (Option B) Endogenous oxytocin is excreted by the pituitary gland and triggers the milk ejection/let-down reflex. Administration of exogenous oxytocin (ie, synthetic oxytocin) has no known effect on milk production. (Option C) Uterine stimulation from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa (ie, abnormal implantation of the placenta over the cervical os) is unrelated to oxytocin administration. Educational objective: Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle and is used to induce or augment labor and to prevent postpartum hemorrhage (PPH). Oxytocin administration increases the risk of abnormal fetal heart rate patterns, emergency cesarean birth, uterine tachysystole, placental abruption, and uterine rupture. Prolonged administration increases the risk of water intoxication and PPH.

Question 8

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?

Accepted Answer

11ecbb05_cc09_afa8_b433_65862b24d765_MD0009_00 Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option A). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. (Option B) Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation. (Option C) Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. (Option D) The nurse should be hypervigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern. Educational objective: Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

Question 9

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply.

Accepted Answer

11ecbb05_cc02_83a8_b433_7dd0de0c99fc_MD0009_00 Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option A). umbilical cord prolapse The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option E). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option B). (Option C) As with any vaginal examination, the client may feel some pressure and discomfort during an amniotomy. However, the actual AROM procedure, or "breaking the bag of water," is painless. (Option D) Supine positioning decreases uteroplacental blood flow and fetal oxygenation. The client should be assisted to upright positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to the cervix. Educational objective: When assisting with an amniotomy, the nurse should assess the fetal heart rate, note the characteristics of the amniotic fluid, and assist the client to an upright position after the procedure.

Question 10

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply.

Accepted Answer

11ecbb05_cc05_b7fc_b433_fba521220f50_MD0009_00 A key indicator of true labor is the progressive effacement and dilation of the cervix (Option E). Contractions in true labor are regular, and increase in frequency, duration, and intensity (Option A). The pain may initially start in the lower back and radiate to the abdomen (Option D). (Option B) True labor contractions will not lessen or dissipate with comfort measures (eg, rest, position change, hydration) and may intensify with walking or activity. Braxton Hicks contractions are irregular contractions that occur throughout pregnancy, and they do not result in cervical change. Although usually mild, they can be increasingly painful and regular for short periods during the last weeks before birth. However, in contrast with true labor, Braxton Hicks contractions will typically lessen with comfort measures. (Option C) Mucoid vaginal discharge that is blood-tinged or brownish (eg, bloody show) is a common finding in the days preceding onset of labor; however, it is not a definitive sign that true labor has started. Educational objective: During true labor, contractions increase in frequency, duration, and intensity over time, resulting in progressive dilation and effacement of the cervix. Clients in true labor often experience discomfort in the lower back that radiates to the abdomen with contractions. Contractions associated with true labor do not lessen or dissipate with comfort measures.

Question 11

A nurse is caring for a client following a forceps-assisted vaginal birth.  The client reports severe vaginal pain and fullness.  On assessment, the nurse notices a firm, midline uterine fundus.  Lochia rubra is light.  Which diagnosis should the nurse anticipate?

Accepted Answer

11ecbb05_cc04_cd99_b433_71ba71fa7368_MD0009_00 A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. (Option A) Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. (Option B) Complete inversion of the uterus presents with a large, red mass protruding from the introitus. (Option C) Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding. Educational objective: Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.

Question 12

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm.  Which uterine assessment finding requires an intervention by the nurse?

Accepted Answer

11ecbb05_cc06_c96e_b433_391d41e72ecc_MD0009_00 Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. (Option B) Uterine frequency should be 2-5 contractions every 10 minutes. If contractions occur less than 2 minutes apart, fetal distress can occur as a result of uteroplacental insufficiency. (Option C) In the first stage of labor, the intensity of uterine contractions should be 25-50 mm Hg. Intrauterine pressure of more than 80 mm Hg is a sign of hypertonicity of the uterus. (Option D) Uterine resting tone of 20 mm Hg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and therefore the fetus, ensuring a well-oxygenated fetus. Educational objective: Uterine contractions during labor dilate and efface the cervix and cause descent of the fetus. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart. Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

Question 13

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor?

Accepted Answer

11ecbb05_cc06_061d_b433_97cb1cc7a6cf_MD0009_00 Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager) (Option A). (Option B) Clients should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal rotation/descent and increase maternal comfort. Remaining in bed during early labor increases the risk for persistent fetal malposition and slows labor progression. (Option C) Left lateral positioning is better for uteroplacental blood flow and fetal oxygenation than supine positioning when the client is resting in bed. However, it may not alleviate the client's back pain. (Option D) Although epidural anesthesia can provide effective pain relief, it can limit client mobility and contribute to persistent fetal malposition. This client is also still in early labor and has not requested an epidural at this time. Educational objective: Fetal occiput posterior position may cause intense back pain during labor. Client comfort can be increased by applying counterpressure to the sacrum during contractions.

Question 14

A pregnant client is brought to the emergency department by ambulance after her water broke. She is screaming and bearing down with every contraction. Which of the following assessment questions are essential to ask in preparation for the birth and possible newborn resuscitation? Select all that apply.

Accepted Answer

When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief, focused history to elicit essential information relevant to potential newborn resuscitation, including: Recent medication or illicit drug use (especially within the last 4 hours): Certain medications and illicit drugs (eg, opioids) may cause respiratory depression in the newborn (Option B). Current pregnancy diagnoses (eg, multiple gestation, placenta previa): Preparation for multiple newborns or high-risk maternal conditions requires more resuscitation equipment and staff (Option C). Color of the amniotic fluid: Meconium-stained fluid may indicate fetal stress or hypoxia during labor, which could require newborn resuscitation after birth (Option D). Expected due date (EDD) or estimated gestational age: A newborn at preterm gestation (<37 weeks gestation) is at risk for respiratory immaturity and may have respiratory distress after birth (Option E). (Option A) When birth is imminent, asking about information that is not immediately pertinent can be frustrating for the client and delay important preparations for the birth. Verifying immunizations is important but it can be delayed until after the client has given birth. Educational objective: When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief history to elicit essential information relevant to potential newborn resuscitation. Identifying clients with recent medication or illicit drug use, multiple gestation or high-risk maternal conditions, meconium-stained amniotic fluid, or preterm gestational age is essential.

Question 15

The nurse is admitting a pregnant client who is experiencing intense "back labor."  The nurse suspects the fetus is in which position?

Accepted Answer

11ecbb05_cc08_2903_b433_a313c2ffc602_MD0009_00 A laboring client may experience lower back pain with contractions, or "back labor," when the fetus is in the right occiput posterior (ROP) position. This variation of vertex presentation causes the fetal occiput to exert added pressure on the woman's sacrum during contractions. Positioning the woman on her hands and knees often helps decrease back pain and facilitates fetal rotation into an anterior position. (Option B) This fetus is in the right occiput anterior (ROA) position, which is optimal for birth as it allows for rotation of the fetal head through the birth canal. (Option C) This fetus is in the right occiput transverse (ROT) position. When the fetus remains in the OP or OT position, labor is often prolonged. Most fetuses in these positions will rotate spontaneously to the OA position during labor. Manual rotation may be attempted with persistent OP or OT position. (Option D) Breech presentation, with the fetal feet or buttocks presenting first in the maternal pelvis, does not cause back labor. Potential complications from breech presentation include ineffective dilation of the cervix and increased risk of umbilical cord prolapse. Educational objective: The occiput posterior position is associated with intense "back labor" due to increased pressure on the maternal sacrum and may result in prolonged labor. Occiput anterior position is optimal for fetal rotation and birth. Breech presentation is associated with ineffective cervical dilation and increased risk of umbilical cord prolapse.

Question 16

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply.

Accepted Answer

Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered via an electronic infusion pump (Option D), which decreases medication errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus. The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option B). Continuous electronic fetal heart rate monitoring, not intermittent auscultation, is necessary (Option C). The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and death. (Option A) Oxytocin is administered through a secondary IV line connected to a main IV line (ie, isotonic fluid) via the port closest to the client (ie, proximal port). This helps prevent an inadvertent oxytocin bolus and allows for rapid discontinuation of infusion. (Option E) Oxytocin is not titrated according to cervical dilation, which cannot be assessed continuously and varies among clients. Instead, oxytocin is initiated at the lowest possible dose and titrated until contractions are 2-3 minutes apart and last for 80-90 seconds. The infusion is decreased/discontinued if uterine tachysystole (ie, >5 contractions in 10 minutes) or fetal distress occurs. Educational objective: Oxytocin is a high-alert medication requiring precise administration via a secondary IV line on an electronic infusion pump and frequent maternal/fetal assessment. The medication is titrated to achieve an adequate contraction pattern without causing uterine tachysystole or fetal distress.

Question 17

The charge nurse is observing fetal heart rate (FHR) tracings of 4 clients who have just been admitted to labor and delivery triage. Which FHR pattern would be most concerning to the nurse?

Accepted Answer

A sinusoidal fetal heart rate (FHR) pattern is characterized by repetitive, wave-like fluctuations with absent variability and no response to contractions; it is usually an ominous finding requiring immediate intervention (Option D). A sinusoidal pattern (ie, a Category III FHR tracing) is suggestive of severe fetal anemia potentially due to fetomaternal hemorrhage (eg, abdominal trauma) or some fetal infections (eg, parvovirus B19). If a sinusoidal pattern is noted, especially after abdominal trauma (eg, fall, motor vehicle collision, injury), the nurse should notify the health care provider immediately, initiate intrauterine resuscitation (eg, positioning, IV fluids, oxygen), and anticipate an expedited birth. (Option A) Fetal tachycardia (ie, FHR baseline >160 beats/min) may be caused by fetal anemia, maternal fever, or infection but is not more concerning than a sinusoidal pattern, particularly in this case because FHR accelerations and moderate variability are present. (Option B) Early decelerations mirror contractions with an apparent, gradual decrease in FHR (ie, ≥30 seconds from onset to nadir). Early decelerations indicate fetal head compression and are a normal finding. (Option C) Variable decelerations are abrupt decreases in the FHR (ie, <30 seconds from onset to nadir) and at least 15 beats/min below baseline for ≥15 seconds to <2 minutes. Variables are usually correctable with maternal position change to relieve umbilical cord compression. If recurrent/prolonged, variable decelerations can impair fetal oxygenation over time. Educational objective: A sinusoidal fetal heart rate pattern is usually an ominous finding associated with severe fetal anemia that requires intrauterine resuscitation and, potentially, an expedited birth.

Question 18

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider?

Accepted Answer

Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option C). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled. (Option A) The perineal area can be cleansed if needed once the placenta has been expelled. (Option B) To avoid uterine inversion or cord avulsion (tearing or snapping), the nurse should not pull on the cord. Once placental separation occurs, signified by cord lengthening, a gush of blood, uterine cramping, and vaginal pressure, the mother can bear down gently to expel the placenta. (Option D) Fundal massage is performed after expulsion of the placenta to increase uterine tone and decrease bleeding. Educational objective: Precipitous birth occurs when delivery takes place ≤3 hours after the onset of contractions. The nurse should prevent newborn cold stress by promptly drying and placing the newborn on the mother's abdomen for skin-to-skin contact.

Question 19

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply.

Accepted Answer

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option D). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option A). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option B). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option E). (Option C) Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be avoided. Lights should be lowered to decrease visual stimuli and risk for seizures. Educational objective: Magnesium sulfate is commonly prescribed to clients with severe preeclampsia to prevent seizures and is a central nervous system depressant. Safety measures for preeclampsia include seizure precautions and decreasing environmental stimuli.

Question 20

The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.

Accepted Answer

The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings. A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenation associated with decreased uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations. Nursing actions to improve fetal perfusion and oxygenation include: Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity (Option C) Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not improve, a right-side position may be attempted (Option B) Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation (Option A) Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental perfusion, especially during maternal hypotension Notifying the health care provider (Option D) (Option E) Nitrazine pH tests are used to detect leaking amniotic fluid, most often if premature (prelabor) rupture of membranes is suspected. This client is at term and in active labor. Educational objective: Late decelerations are evidence of impaired fetal oxygenation. Discontinuing the oxytocin infusion, changing maternal position, administering oxygen, and giving an IV fluid bolus are essential interventions.

Exam 6: Maternal & Newborn Health

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply.

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client?

The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain?

The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action?

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action?

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply.

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate?

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse?

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor?

The nurse is admitting a pregnant client who is experiencing intense "back labor." The nurse suspects the fetus is in which position?

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply.

The charge nurse is observing fetal heart rate (FHR) tracings of 4 clients who have just been admitted to labor and delivery triage. Which FHR pattern would be most concerning to the nurse?

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider?

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply.

The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.