Problems with Labor and Birth: Saunders NCLEX Review

Problems with Labor and Birth: Saunders NCLEX Review

Leave the first rating Students also studied Terms in this set (13) Science MedicineObstetrics Save Labor & Delivery Saunders NCLEX q...80 terms Preview Risk Conditions Related to Pregnan...64 terms kaseygibbPreview Labor and Delivery Nclex style ques...46 terms athingofaithPreview Abrupt 10 terms kiw The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

• Soft abdomen
• Uterine tenderness
• Absence of abdominal pain
• Painless, bright red vaginal bleeding

2

Rationale: Abruptio placentae is the premature separation of the placenta from

the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio pla- centae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdo- men feels hard and boardlike on palpation as the blood pen- etrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the sec- ond or third trimester of pregnancy are signs of placenta previa.The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

• Prepare the client for an ultrasound.
• Obtain equipment for a manual pelvic examination.
• Prepare to draw a hemoglobin and hematocrit blood

sample.

• Obtain equipment for external electronic fetal heart

rate monitoring.2

Rationale: Placenta previa is an improperly implanted placenta in the lower

uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and pla- centa previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

• Delivery of the fetus
• Strict monitoring of intake and output
• Complete bed rest for the remainder of the pregnancy
• The need for weekly monitoring of coagulation studies

until the time of delivery 1

Rationale: Abruptio placentae is the premature separation of the placenta from

the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of man- agement in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treat- ment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

• The client is a 35-year-old primigravida.
• The client has a history of cardiac disease.
• The client's hemoglobin level is 13.5 g/dL (135 mmol/L).
• The client is a 20-year-old primigravida of average

weight and height.2

Rationale: Preterm labor occurs after the twentieth week but before the thirty-

seventh week of gestation. Several factors are associated with preterm labor, including a history of med- ical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdis- tention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

• Age 54
• Body mass index of 28
• Previous difficulty with fertility
• Administration of oxytocin for induction
• Potassium level of 3.6 mEq/L (3.6 mmol/L)

1,2,3

Rationale: Risk factors that increase a woman's risk for dys- functional labor

include the following: advanced maternal age, being overweight, electrolyte

imbalances, previous diffi- culty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehy- dration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with infertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6mmol/L) is normal and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstim- ulation occurs.The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise.Which assessment finding should alert the nurse to a compromise?

• Maternal fatigue
• Coordinated uterine contractions
• Progressive changes in the cervix
• Persistent nonreassuring fetal heart rate

4

Rationale: Signs of fetal or maternal compromise include a persistent,

nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium.Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoor- dinated contractions that are erratic in their fre- quency, duration, and intensity. What is the priority nursing action?

• Provide pain relief measures.
• Prepare the client for an amniotomy.
• Promote ambulation every 30 minutes.
• Monitor the oxytocin infusion closely.

1 Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary inter- vention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hyper- tonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.The nurse is reviewing the health care provider's(HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

• Monitor fetal heart rate continuously.
• Monitor maternal vital signs frequently.
• Perform a vaginal examination every shift.
• Administer an antibiotic per HCP prescription and per

agency protocol.3

Rationale: Vaginal examinations should not be done routinely on a client with

premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

• Providing comfort measures
• Monitoring the fetal heart rate
• Changing the client's position frequently
• Keeping the significant other informed of the progress

of the labor 2

Rationale: Dystocia is difficult labor that is prolonged or more painful than

expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the cli- ent's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

• Slow the intravenous flow rate.
• Continue the oxytocin drip if infusing.
• Place the client in a high Fowler's position.
• Administer oxygen, 8 to 10 L/minute, via face mask.

4

Rationale: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize

oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect because oxy- tocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion.

The nurse in the postpartum unit is caring for a cli- ent who has just delivered a newborn infant fol- lowing a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to mon- itor the client for which risk associated with pla- centa previa?

• Infection
• Hemorrhage
• Chronic hypertension
• Disseminated intravascular coagulation

2

Rationale: In placenta previa, the placenta is implanted in the lower uterine

segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding.Options 1, 3, and 4 are not risks that are related specifically to placenta previa.The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

• Uterine rigidity
• Uterine tenderness
• Severe abdominal pain
• Bright red vaginal bleeding
• Soft, relaxed, nontender uterus
• Fundal height may be greater than expected for

gestational age 4,5,6

Rationale: Placenta previa is an improperly implanted pla- centa in the lower

uterine segment near or over the internal cer- vical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.The cli- ent has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio pla- centae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio pla- centae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

• Gently push the cord into the vagina.
• Place the client in Trendelenburg position.
• Find the closest telephone and page the health care

provider stat.

• Call the delivery room to notify the staff that the client

will be transported immediately.2

Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord

compression and increase fetal oxygena- tion. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the dia- phragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation.