Deck 23: Nursing Care of a Family Experiencing a Complication of Labor or Birth

Question 1

A pregnant patient in labor is having contractions 2 minutes apart but rarely over 50 mmHg in strength; the resting tone is high, 20 to 25 mmHg. The patient asks what can be done to make contractions more effective. What should the nurse respond to the patient?

A) Rest because contractions are hypertonic.
B) Receive oxytocin to strengthen contractions.
C) Hypotonic contractions of this kind will strengthen by themselves.
D) Walking around will make the contractions more regular.

Answer 1

Rest because contractions are hypertonic.

Question 2

A patient in labor has been prescribed an intravenous infusion of 5% dextrose/water. Following insertion of the intravenous line, what should the nurse instruct the patient to do?

A) Try to forget the fluid line is in place.
B) Lie on the back to allow optimal flow.
C) Not to get out of bed once the needle is in place.
D) Lie perfectly still so as not to dislodge the needle.

Answer 2

Try to forget the fluid line is in place.

Question 3

A patient in labor has reached 8 cm dilation, but the fetal heart rate suddenly slows. Perineal inspection reveals a prolapsed fetal cord. What should the nurse do first?

A) Turn the patient onto the left side.
B) Replace the cord with gentle pressure.
C) Place the patient in a knee-chest position.
D) Cover the exposed cord with a dry, sterile wrap.

Answer 3

Place the patient in a knee-chest position.

Question 4

A pregnant patient is prescribed to have labor induced with oxytocin. How should the nurse prepare to administer this medication?

A) In a 20-cc bolus of saline
B) In two divided intramuscular sites
C) Diluted as a "piggyback" infusion
D) Diluted in the main intravenous fluid

Question 5

After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting. What should the nurse do?

A) Assess the vagina for full dilation.
B) Notify the physician and stop the infusion.
C) Instruct the patient to breathe in and out rapidly.
D) Administer oral orange juice for added potassium.

Question 6

A pregnant patient receiving intravenous oxytocin for 1 hour has contractions lasting 80 seconds. What should the nurse do first for this patient?

A) Discontinue the oxytocin infusion.
B) Slow the infusion to below 10 gtt/minute.
C) Increase the flow rate of the main line infusion.
D) Continue to monitor contraction duration every 2 hours.

Question 7

The nurse is assessing a patient in labor. On which complication of labor as identified within the 2020 National Health Goals will the nurse focus?

A) Uterine rupture
B) Prolapsed fetal cord
C) Hypotonic contractions
D) Hypertonic contractions

Question 8

An infant was born after a face presentation. When selecting a nursing diagnosis for the newborn, which body system does the nurse identify as a priority?

A) Respiratory
B) Genitourinary
C) Cardiovascular
D) Gastrointestinal

Question 9

The fetus of a pregnant patient is in a breech presentation. Where will the nurse auscultate fetal heart sounds?

A) Low in the abdomen
B) Left lateral abdomen
C) High in the abdomen
D) Right lateral abdomen

Question 10

A patient is experiencing dysfunctional labor, which is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient?

A) Oxytocin therapy
B) Fluid replacement
C) Pain management
D) Increasing activity

Question 11

After delivery, a patient is diagnosed with placenta succenturiata. For what procedure should the nurse prepare this patient?

A) Lavage of the uterus
B) Repair of an episiotomy
C) Manual removal of accessory lobes
D) Emergency resuscitation of the newborn

Question 12

The nurse is caring for a patient in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this patient's discomfort?

A) Massage the lower back.
B) Place in a prone position.
C) Apply ice packs to the lower back.
D) Place in the Trendelenburg position.

Question 13

While the placenta is being delivered after labor, a patient experiences an amniotic fluid embolism. What should the nurse do first to help this patient?

A) Administer oxygen by mask.
B) Increase intravenous fluid infusion rate.
C) Put firm pressure on the fundus of the uterus.
D) Tell the patient to take short, shallow breaths.

Question 14

A patient in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will be used. What should the nurse do to prepare the patient for this type of delivery? (Select all that apply.)

A) Provide oxygen 2 L via face mask.
B) Validate that the cervix is fully dilated.
C) Determine that the patient's bladder is empty.
D) Begin an intravenous infusion of replacement fluid
E) Ensure that the patient's membranes have ruptured.

Question 15

The nurse is evaluating care provided to a patient giving birth to her first child. Which outcome regarding labor indicates that care has been effective?

A) Client achieved 4 cm of dilation after 7 hours of labor.
B) Client achieved full dilatation after 8 hours of labor.
C) Client delivered infant within 2 hours after full dilatation with epidural.
D) Client delivered infant within 30 minutes after full dilatation without epidural.

Question 16

A pregnant patient tells the nurse that she hopes the baby is not in the breech position because she has heard that this causes difficult labor. What should the nurse include when explaining the reasons for this presentation to the patient? (Select all that apply.)

A) Multiple fetuses
B) Maternal diabetes
C) Fetal birth defects
D) Lax abdominal muscles
E) Fetal age less than 40 weeks