- Information
- AI Chat
Chapter 08 nursing care of women with complications during labor and birth
Maternity/Peds (PRN06900)
McFatter Technical College
Recommended for you
Students also viewed
- Done How did British and Chinese points of view concerning trade between the two nations differ How were they similar
- Done What is globalization What can a t-shirt reveal about it
- Compare Essay Done
- Chapter 05 nursing care of women with complications during pregnancy
- Chapter 09 the family after birth
- Chapter 01 the past present and future free
Related documents
- Chapter 02 human reproductive anatomy and physiology free
- Chapter 04 prenatal care and adaptations to pregnancy
- Chapter 10 nursing care of women with complications after birth
- Chapter 07 nursing management of pain during labor and birth
- AP Psychology Unit 1 - AP Psych notes
- CARE PLAIN FOR POST OP PATIENT FROM SPLEEN RUPTURE
Preview text
Chapter 08: Nursing Care of Women with Complications During Labor and Birth
MULTIPLE CHOICE
- What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37 C. ANS: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.
DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 TOP: Obstetric ProceduresAmniotomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
- A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurses initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask. ANS: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.
DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 TOP: Obstetric ProceduresInduction of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
- What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema ANS: B Ice is applied to the perineum to reduce bruising and edema.
DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 TOP: Obstetric ProceduresLacerations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False ANS: B The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.
DIF: Cognitive Level: Comprehension REF: Page 187, Box 8- OBJ: 5 TOP: Abnormal Labor KEY: Nursing Process Step: Data Collection
file:///D|/..%207th%20Ed%20TEST%20BANK/chapter-08-nursing-care-of-women-with-complications-during-labor- and-birth[21/04/2019 14:42:59]
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12 ANS: A The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG).
DIF: Cognitive Level: Comprehension REF: Page 175, Table 8- OBJ: 2 TOP: Bishop Scoring for Vaginal Delivery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
file:///D|/..%207th%20Ed%20TEST%20BANK/chapter-08-nursing-care-of-women-with-complications-during-labor- and-birth[21/04/2019 14:42:59]
- A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported and give her a back massage b. Supine with legs bent at the knee c. Standing with support d. Sitting up and leaning forward on the over-bed table ANS: D A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.
DIF: Cognitive Level: Application REF: Page 189- OBJ: 7 TOP: Abnormal Labor KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
- The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery. ANS: C The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.
DIF: Cognitive Level: Application REF: Page 191- OBJ: 6 TOP: Abnormal Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism ANS: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.
Which statement indicates a woman understands activity limitations for the management of preterm labor? a. After my shower in the morning, I do the laundry and straighten up the house; then I rest. b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day. c. I have a 2-year-old to care for, but I try to rest as much as I can. d. I get really bored at home, so I go to the shopping mall for just a little while. ANS: B Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.
DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5 TOP: Preterm Labor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by walking fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift. ANS: B Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.
DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4 TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. On her back with her head lower than the rest of her body d. Supine with her legs elevated and bent at the knee ANS: C The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.
DIF: Cognitive Level: Application REF: Page 195 OBJ: 8 TOP: Emergencies During ChildbirthProlapsed Umbilical Cord KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
- Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience ANS: D Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.
DIF: Cognitive Level: Application REF: Page 183 OBJ: 8 TOP: Cesarean Section KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
- A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity.
file:///D|/..%207th%20Ed%20TEST%20BANK/chapter-08-nursing-care-of-women-with-complications-during-labor- and-birth[21/04/2019 14:42:59]
- During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub. ANS: B Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.
DIF: Cognitive Level: Application REF: Page 195 OBJ: 3 TOP: Uterine Rupture KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- What does the nurse explain is used to soften the cervix with a cervical ripening agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches
file:///D|/..%207th%20Ed%20TEST%20BANK/chapter-08-nursing-care-of-women-with-complications-during-labor- and-birth[21/04/2019 14:42:59]
d. Nipple stimulation ANS: A Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.
DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3 TOP: Cervical Ripening KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix. ANS: B Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.
DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6 TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous cesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy ANS: C A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth.
DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7 TOP: Precipitate Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain e. Edematous labia ANS: B Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation. All the other options are normal findings for late pregnancy.
DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- What are the rationales for labor induction? (Select all that apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency ANS: D, E Maternal diabetes and placental insufficiency are rationales for induction. The other options are contraindications for labor induction.
DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2 TOP: Rationales for Labor Induction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
- Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration ANS: A, B, C Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor.
DIF: Cognitive Level: Application REF: Page 177 OBJ: 3 TOP: Hypotonic Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What complications of overstimulation of uterine contractions may occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture ANS: A, B, E The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.
DIF: Cognitive Level: Comprehension REF: Page 178 OBJ: 6 TOP: Complication of Oxytocin KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast.
file:///D|/..%207th%20Ed%20TEST%20BANK/chapter-08-nursing-care-of-women-with-complications-during-labor- and-birth[21/04/2019 14:42:59]
case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.
DIF: Cognitive Level: Application REF: Page 175- OBJ: 3 TOP: Cervical Ripening KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
COMPLETION
- After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________.
ANS: amnioinfusion
A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord.
file:///D|/..%207th%20Ed%20TEST%20BANK/chapter-08-nursing-care-of-women-with-complications-during-labor- and-birth[21/04/2019 14:42:59]
DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3 TOP: Amnioinfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
- _____________________________ is a lower-than-normal amount of amniotic fluid.
ANS: Oligohydramnios
Oligohydramnios is a lower amount than normal of amniotic fluid.
DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1 TOP: Amniotic Fluid KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Reduction of Risk
- A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions.
ANS: laminaria
A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water.
DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1 TOP: Laminaria KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
Chapter 08 nursing care of women with complications during labor and birth
Course: Maternity/Peds (PRN06900)
University: McFatter Technical College
- Discover more from:
Students also viewed
- Done How did British and Chinese points of view concerning trade between the two nations differ How were they similar
- Done What is globalization What can a t-shirt reveal about it
- Compare Essay Done
- Chapter 05 nursing care of women with complications during pregnancy
- Chapter 09 the family after birth
- Chapter 01 the past present and future free
Related documents
- Chapter 02 human reproductive anatomy and physiology free
- Chapter 04 prenatal care and adaptations to pregnancy
- Chapter 10 nursing care of women with complications after birth
- Chapter 07 nursing management of pain during labor and birth
- AP Psychology Unit 1 - AP Psych notes
- CARE PLAIN FOR POST OP PATIENT FROM SPLEEN RUPTURE