MIDTERM: NCM 109 Care of Mother and Child at

risk or with problems (OB2)

Practice Questions: Chapter 23: Nursing Care of a Family Experience a Complication of
Labor or Birth
1. A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is
cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth

If the cause of the delay in dilation (dilatation) is fetal malposition or cephalopelvic disproportion (CPD), cesarean birth may be necessary. Oxytocin would be
administered to augment labor only if CPD were ruled out. Administration of morphine sulfate (an analgesic) and darkening room lights and decreasing noise and
stimulation are used in the management of a prolonged latent phase caused by hypertonic contractions. These measures would not help in the case of CPD.

2. A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the
past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it
comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

Occiput posterior position

A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay
term for this type of labor is "back labor."

3. After only 45 minutes of labor, the client feels the urge to push. She pushes once and the baby's head is visible. With the next push, the head emerges.
What is the immediate risk when the head is delivered too fast?

Perineal tearing

The immediate risk of a precipitous delivery is perineal tearing, because the tissue does not have time to stretch naturally. Vaginal stretching has occurred as the
fetus descended to the perineum. Bladder incontinence and pelvic floor relaxation are potential long-term consequences of a precipitous birth, but they are not the
immediate concern.

4. After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

knee-chest

Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-
lying, or sitting would not provide relief of cord compression.

5. Although many women envision a plan of how labor will go, sometimes complications happen, and their plan is no longer achievable. When this happens,
what is the best question the nurse can ask the woman at this time?

"What do you consider your primary goal for the outcome of this pregnancy?"

If a complication of labor or birth occurs, identification of expected outcomes can be difficult because an outcome that must be included in planning may not be what
the woman desires. Encouraging a couple to clarify their priorities when a complication occurs is helpful. Asking "if the baby knows" is trying to provoke humor and is
inappropriate at this time. Asking if plans have ever changed in the middle of a project does not focus on the ultimate goal of delivering a healthy baby. Trying to find
out how a client deals with unanticipated changes does not focus on the priority of a healthy baby.

6. A client arrives in labor and delivery following a motor vehicle accident. She was sitting in the passenger seat and wearing a seat belt. On admission the
nurse notes vaginal bleeding. The client says she is 30 weeks' pregnant, but only had an initial prenatal visit during which the pregnancy was confirmed.
The external monitor shows irregular uterine contractions and a fetal heart rate of 152. The provider orders an ultrasound examination prior to
establishing a plan of care. What is the priority purpose for an ultrasound examination in this situation?

Determine placental location

In this situation, there is vaginal bleeding and abdominal trauma. Prior to making a plan of care, an ultrasound examination is needed to determine placental location
and rule out a placenta previa. Knowing placental location will help the provider to determine if the vaginal bleeding is from a placenta previa or a placental abruption
(abruptio placentae). Fetal position, biparietal diameter, and a biophysical profile are all procedures performed during an ultrasound examination, but they are not a
priority at this time.

7. A client has arrived at the labor and delivery suite for a scheduled induction of labor. Which nursing intervention should the nurse implement before
starting the oxytocin infusion?

Assessing for uterine contractions

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Nursing care of the client before oxytocin infusion begins should include assessing for uterine contractions and rupture of membranes along with other interventions
like assessing baseline vital signs and fetal heart rate. Continuously monitoring fetal heart rate and uterine activity, assessing blood pressure and pulse hourly or more
often if required, and documenting uterine activity and fetal heart rate are interventions required during oxytocin infusion, and not before starting the oxytocin
infusion. Fetal kick counts are documented to assess fetal wellbeing during pregnancy. A urine specimen is not required.

8. A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9
mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?

hypotonic contractions

With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting
tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an
increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In
contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely
together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without
any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that
occur in pregnancy before the onset of true labor.

9. A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for
shoulder dystocia?

diabetes

Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse
lie fetal position not with shoulder dystocia.

10. A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the
umbilical cord in this client?

Assess fetal heart sounds.

To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the
fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to
therapeutic interventions to implement once cord prolapse has been confirmed.

11. A client with a pendulous abdomen and uterine fibroid tumors has just begun labor and arrived at the hospital. After examining the client, the primary care
provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in
this woman?

transverse lie

A transverse lie, in which the fetus is more horizontal than vertical, occurs in the following instances: women with pendulous abdomens; uterine fibroid tumors that
obstruct the lower uterine segment; contraction of the pelvic brim; congenital abnormalities of the uterus; or hydramnios. Anterior fetal position and cephalic
presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelvis.

12. The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?

Pain relief measures

Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and back rubs may
be helpful. Position changes that can promote fetal head rotation are important and can help to relieve some of the pain. Additionally, the woman's ability to
cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is
evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.

13. A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood
pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of
which complication?

Uterine rupture

The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and
in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

14. A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder
dystocia. What intervention can the nurse assist with to help with the birth?

McRoberts maneuver

The McRoberts maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position,
while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to
deliver in almost half of the cases.
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 15. A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best
illustrates a power problem?

Uterine contractions are weak and ineffective.

Labor dystocia indicates that the labor is progressing too slowly. Reasons for this are described as due to the "four P's", which are passageway, passenger, power and
psyche. A power problem involves either ineffective contractions in either quality or quantity or the mother is too tired to push when needed.

16. A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving
magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

Respiratory depression, hypotension, absent tendon reflexes

Magnesium sulfate is a smooth muscle relaxant and can cause vasodilation and results in respiratory depression and severe hypotension at toxic levels. The other
options are incorrect indications of magnesium sulfate toxicity.

17. A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic
disproportion is ruled out. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin

Oxytocin would be appropriate for the woman experiencing dysfunctional labor (hypotonic uterine dysfunction). Comfort measures minimize the woman's stress and
promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used if the membranes were intact. It may also be used with
hypotonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

18. The nurse cared for a client who gave birth. The duration of labor from the onset of contractions until the birth of the baby was 2 hours. How will the nurse
document the client's labor in the health record?

Precipitous labor

A labor that is less than 3 hours in duration is a precipitous labor. Prolonged labor, also known as failure to progress, occurs when labor lasts for approximately 20
hours or more in a first-time mother. Prodromal labor is labor that starts and stops before fully active labor begins. The contractions are real, but they come and go,
and labor does not progress. False labor is intermittent nonproductive or practice contractions, which most commonly occur in the last 2 months before a full-term
delivery.

19. The nurse in a busy L & D unit is caring for a woman beginning induction via oxytocin drip. Which prescription should the nurse question with regard to
titrating the infusion upward for adequate contractions?

Begin infusion at 10 milliunits (mu)/min and titrate every 15 minutes upward by 5 mu/min.

Hyperstimulation is usually defined as five or more contractions in a 10-minute period or contractions lasting more than 2 minutes in duration or occurring within 60
seconds of each other. The surest method to relieve hyperstimulation is to immediately discontinue the oxytocin infusion. The rate should not be increased by more
than 2 milliunits at a time. When the infusion is administered, the oxytocin solution should be "piggybacked" to a maintenance IV solution such as Ringer's lactate and
the piggyback added to the main infusion at the port closest to the woman. Infusions are usually begun at a rate of 1 to 2 milliunits/min. If there is no response, the
infusion is gradually increased every 30 to 60 minutes by small increments of 1 to 2 milliunits/min until contractions begin.

20. Therse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After
notifying the RN and primary care provider, which action should the LPN prioritize?

Prepare to assist with external version.

Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position or be born via cesarean birth. Piper
forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina.
Counterpressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior
(OP) positioning.

21. The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum

Caput succedaneum is a complication that may occur in the newborn of a woman who had a forceps-assisted birth. Maternal complications include tissue trauma
such as lacerations of the cervix, vagina, and perineum; hematoma; extension of episiotomy into the anus; hemorrhage; and infection.

22. The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which
action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

Use McRoberts maneuver.

McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person
or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal

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head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice
for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

23. The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

Sudden shortness of breath

Sudden shortness of breath can be a sign of amniotic fluid embolism and requires emergent intervention. This can occur suddenly during labor or immediately after.
The woman usually develops symptoms of acute respiratory distress, cyanosis, and hypotension. It must be reported to the care team so proper interventions may be
taken. Other symptoms can include hypotension, cyanosis, hypoxemia, uterine atony, seizures, tachycardia, coagulation failure, DIC, and pulmonary edema.

24. The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist with the
birth?

Abnormal position of the fetal head

Forceps are mechanical devices which can be used to help deliver the fetus. Although no longer used routinely they are still used in certain situations to assist with
the birth. One of those situations is when the fetus is in an abnormal position and the health care provider attempts to reposition the fetus to facilitate birth. The use
of forceps is not to lessen the mother's pain or to speed up the process. The use of forceps is not without risk of complications, include perineal lacerations and injury
to the fetus if the forceps are not used correctly.

25. The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?

Late decelerations

When the fetus is being deprived of oxygen the fetus will demonstrate late decelerations on the fetal monitoring strip. This is an indication the mother is in need of
further assessment. Early decelerations are a normal finding. Variable decelerations usually coincide with cord compression.

26. A nurse is caring for a client who is diagnosed with a breech presentation and in the transition stage of labor. The nurse is aware that which is common at
birth?

A thick meconium

During a vaginal delivery of a breech presentation, the nurse expects to see a thick meconium as the buttocks are squeezed during labor. The presence of meconium
does not necessarily indicate fetal distress and the meconium is not mixed with amniotic fluid. Although a difficult delivery for the mother, uterine rupture is not
common. Fetal tachycardia is not commonly related to a breech presentation.

27. The nurse is caring for a woman undergoing cervical dilation. Which assessment finding would alert the nurse to the complication of vasa previa?

Painless bleeding at the beginning of cervical dilation

Painless bleeding at the beginning of cervical dilation (due to vessel tearing) is a sign of vasa previa. Rapid cervical dilation and effacement are indicative of
precipitous birth. Meconium staining may be noted with a breech birth.

28. Therse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based
on which contraction finding?

erratic

Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than
one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality, brief, and lack sufficient intensity to dilate and efface the
cervix.

29. The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression.

Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity,
preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully; descent in the pelvis; abnormal fetal
heart rate patterns or acute pulmonary edema; and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for
amniofusion.

30. A nursing instructor identifies which of the following as increasing the chances of infection when coupled with prolonged labor?

ruptured membranes

The risk for infection increases during prolonged labor particularly in association with ruptured membranes. The other options do not increase the risk of infection
during labor.

31. A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
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increasing birth weight.

Shoulder dystocia is the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has emerged. The incidence of shoulder dystocia is
increasing because of increasing birth weights, with reports of it in as many as 2% of vaginal births.

32. The nursing student demonstrates an understanding of dystocia with which statement?

"Dystocia is diagnosed after labor has progressed for a time."

Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client
and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.

33. A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take
place. This means the labor will be completed in which span of time?

less than 3 hours

Precipitous labor is completed in less than 3 hours.

34. A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the
following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal."

In most term pregnancies the fetus presents head down. In a breech presentation, the fetal buttocks, feet, or both present to the birth canal. Transverse lie is the
same as shoulder presentation.

35. A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the
fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect
to prepare the client for which testing to confirm the suspicion?

ultrasound

A client experiencing an intrauterine fetal demise (IUFD) is likely to seek care when she notices that the fetus is not moving or when she experiences contractions, loss
of fluid, or vaginal bleeding. History and physical examination frequently are of limited value in the diagnosis of fetal death, since many times the only history tends to
be recent absence of fetal movement and no fetal heart beat heard. An inability to obtain fetal heart sounds on examination suggests fetal demise, but an ultrasound
is necessary to confirm the absence of fetal cardiac activity. Once fetal demise is confirmed, induction of labor or expectant management is offered to the client. An
amniocentesis, hCG level, or triple marker screening would not be used to confirm IUFD.

36. A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she may be in labor. To determine if the client is experiencing labor, which
question(s) would be appropriate for the nurse to ask? Select all that apply.

"Are you feeling any pressure or heaviness in your pelvis?"

"Are you having contractions that come and go, off and on?"

"Have you noticed any fluid leaking from your vagina?"

"Have you been having any nausea or vomiting?"

Frequently, women are unaware that uterine contractions, effacement, and dilation are occurring, thus making early intervention ineffective in arresting preterm
labor and preventing the birth of a premature newborn. The nurse should ask the client about any signs/symptoms, being alert for subtle symptoms of preterm labor,
which may include: a change or increase in vaginal discharge with mucous, water, or blood in it; pelvic pressure (pushing-down sensation); low dull backache;
menstrual-like cramps; urinary tract infection symptoms; feeling of pelvic pressure or fullness; gastrointestinal upset like nausea, vomiting, and diarrhea; general
sense of discomfort or unease; heaviness or aching in the thighs; uterine contractions with or without pain; more than six contractions per hour; intestinal cramping
with or without diarrhea. Contractions also must be persistent, such that four contractions occur every 20 minutes or eight contractions occur in 1 hour. A report of
heartburn is unrelated to preterm labor.

37. A pregnant client's labor has been progressing slower than normal. The client is visibly anxious and tense, telling the nurse, "I am so worried about what is
going to happen. And I am so tired and feel so helpless." Other underlying issues that may be contributing to the client's slow labor progress have been
ruled out. Which response(s) by the nurse would be appropriate? Select all that apply.

"Maybe dimming the lights or some soft music will help you relax a bit."
"I will keep you updated often on how you and your baby are doing."
"Things are moving along but sometimes it can take a little longer."

The client is experiencing problems with the psyche. The nurse should provide emotional support to the client and family. Comfort measures such as
dimming the lights or putting on soft music can promote relaxation and help the client's body work more effectively with the forces of labor. Keeping the
client updated about her status and that of her fetus can provide reassurance and encouragement. Explanations about labor and what to expect can help

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 empower the client and help her cope. The nurse should provide continuous presence to allay anxiety. Pain medication is needed to reduce anxiety and
stress.
38. A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse
would assess the woman for which condition?

fetopelvic disproportion

The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta,
contraction ring, or uterine bleeding would not be associated with a change in labor pattern.

39. Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot
take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?

McRoberts maneuver

McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two
individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse
holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in
almost half of the cases.

40. A shoulder dystocia situation is called in room 4. The nurse enters the room to help and the health care provider says to the nurse, "McRoberts
maneuver." What does the nurse do next?

Bring the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic symphysis

To implement McRoberts maneuver, the nurse brings the client's knees back toward the shoulders, causing hyperflexion of the hips and rotation of the pubic
symphysis. This maneuver enlarges the space for delivery of the fetal shoulders. Applying pressure above the pubic bone is suprapubic pressure. Pushing the fetal
head back into the vagina is a Zavanelli maneuver. Since the fetal head has been delivered, it is not safe to move the client to a hands-and-knees position.

41. Whatminology would the nurse use to document a newborn who weighs 4,000 grams (8.8 lb) or more at birth?

macrosomia

Macrosomia, in which a newborn weighs 4,000 to 5,000 grams (8.8 to 11 lb) or more at birth, complicates approximately 10% of all pregnancies. Meconium is the first
stool passed by a newborn. Hydrocephalus is a build-up of fluid inside the skull.

42. When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding.

Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth
after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues
happens if the cup slips off the fetal head and the suction is not released.

43. Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction?

contractions most forceful in the middle of uterus rather than the fundus

Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are
associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation (dilatation) that has
not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

44. Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status

Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about
the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is
the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating
the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.

45. Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.

Hypertonic contractions cause uterine cell anoxia, which is painful.

46. A woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been
progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse
suspect?

Uterine rupture
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A uterine rupture should be suspected in a pregnant woman who has experienced blunt trauma to the abdomen and then complains of severe pain in her back and
shoulder. Uterine rupture occurs when the uterus tears open, leaving the fetus and other uterine contents exposed to the peritoneal cavity. Traumatic rupture can
occur in connection with a blunt trauma. Abrupt change in the fetal heart rate pattern is often the most significant sign associated with uterine rupture. Other signs
are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. The scenario presented does
not indicate fractured ribs from the accident. Placental abruption (abruptio placentae) presents with pain; dark red vaginal bleeding; a rigid, board-like abdomen;
hypertonic labor; and fetal distress. Pain has a sudden onset and is constant, and the uterus may not relax well between contractions. Dystocia is the abnormally slow
progression of labor, which is not indicated.

47. A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the
provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question?

"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."

Arrest of descent results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara. The most likely cause for arrest of descent during the
second stage is CPD. Rest should allow the uterine contractions to be more efficient. The hormones secreted during pregnancy allow ligaments to soften so bones can
shift to allow birth. Ultrasound would have previously been diagnosed prior to the onset of labor.

48. A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the
shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours
later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include
which outcome statement?

The parents are beginning to demonstrate positive grieving behaviors.

An evaluation of proposed outcomes may reveal unhappiness because not every woman who experiences a deviation from the normal in labor and birth will be able
to give birth to a healthy child. Some infants will die. Outcome achievement might include the client begins positive grieving behaviors (touching, counting
toes/fingers, etc.) in response to the loss of the newborn. The other statements are probably accurate but are not written as outcome statements.

49. A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the
woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm
and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client
may be experiencing which complication?

uterine rupture

If a uterus should rupture, the woman experiences a sudden, severe pain during a strong labor contraction, which she may report as a "tearing" sensation. Because
the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate emergency. Signs of hypotensive shock begin, including a rapid, weak
pulse, falling blood pressure, cold and clammy skin, and dilation of the nostrils from air starvation. Fetal heart sounds fade and then are absent

50. A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the
nurse expect to administer?

uterine stimulants

For hypotonic labor, a uterine stimulant such as oxytocin may be prescribed once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with
hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal
lung maturity for women experiencing preterm labor.

51. A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a
contraction. What is the highest priority fetal assessment the health care provider should focus on at this time?

Look for late decelerations on monitor, which is associated with fetal anoxia.

A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early
in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the
FHR is not showing late deceleration.

52. A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal
heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be
appropriate for this mother at this time?

Offer to take pictures and footprints of the infant once it is delivered.

When parents are faced with a fetal death, they need comfort and support without being intrusive. Taking pictures, footprints and gathering other mementos are
very important in helping the family deal with the death. The mother is encouraged to hold the infant after delivery and name it. Telling the parents that the infant
was probably defective is hurtful and not supportive to them. Calling the hospital chaplain is something that can be offered but should not be done without the
parent's approval.

53. A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and maintains the infusion at the prescribed rate based on which
finding?

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Respiratory rate of 16 breaths/minute

A respiratory rate of 16 breaths per minute is appropriate and within acceptable parameters to continue the infusion. When administering magnesium sulfate, the
nurse would immediately report decreased fetal heart rate variability, a urine output less than 30 ml/hour, and decreased or absent deep tendon reflexes.

54. A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of
fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which
condition would the nurse suspect?

uterine rupture

Uterine rupture is associated with crack cocaine use disorder. Generally, the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain,
vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of
respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the
protrusion of the cord alongside or ahead of the presenting part of the fetus.

55. Rosann Bigalow states that her contractions are irre9 ular in frequency and short in duration. She screams in pain, however, every time she has a
contraction. What action by the nurse would be best?
A. Recognizes is a usual response to labor and offer her a back rub.
B. Notify the anesthesiologist that Rosann needs to have epidural
C. Obtain a prescription from her primary care provider for an analgesic.
D. Document/report frequency and duration of contractions plus facilitate pain relief.

D. It would be important for the nurse to document the characteristics of Rosann's contractions to see if they are irregular; even though ineffective. they are still
painful so she needs pain relief.

56. Rosann's primary care provider is considering whether to augment her labor with oxytocin. What would make the nurse question the care provider's
use of oxytocin for her?

A. Her blood pressure is slightly elevated above normal.

B. Her membranes ruptured after only 1 hour of labor.
C. Her fetus is large for gestational age by a sonogram.
D. She had an amniocentesis performed during pregnancy.

C. The nurse would question her labor augmentation with oxytocin because with a large fetus cephalo pelvic disproportion may be present. Amniocentesis, elevated
blood pressure, and ruptured membranes do not contraindicate the use oxytocin.

57. The nurse notices Rosann's contractions are 70 seconds long and occur every 90 seconds when assessing frequency of her contractions after she
receives oxytocin. What would be the nurse's first action?

A. Ask Rosann to turn onto her left side and breathe deeply.
B. Increase the rate of Rosann's IV fluid infusion.
C. Discontinue the administration of the oxytocin infusion.
D. Give an emergency bolus of oxytocin to relax the uterus.

C. Discontinuing the oxytocin infusion would be the nurse's first step in the management of Rosann's change in labor progress. Turning to the left side and increasing
fluid are second and third steps.

58. Rosann's baby is not only large but also in an occipitoposterior position. The nurse would want the team members to know which position is best for a
woman whose baby is in the occipitoposterior position during labor?

A. On her right side to stretch the pelvic inlet

B. Walking about to encourage fetal descent
C. Sitting in a rocking chair to aid presentation
D. On her hands and knees to help fetal rotation

D. Although not evidence based, the nurse would want team members to know a hands-and-knees position appears to aid fetal occipital rotation more than the other
listed positions.

59. To determine which risk factors were associated with shoulder dystocia, researchers studied a cohort of births from 1967 to 2009 in Norway, a sample
of 2,014,956 vaginal births. The results of the study found an increased incidence of shoulder dystocia associated with increased fetal weight, maternal
diabetes, prolonged labor, instrumental delivery and parity (Øverland, Vatten, & Eskild, 2014).

Based on this study and the fact that a sonogram has shown Rosann's fetus to be extremely large, what assessment would the nurse want to prioritize for Rosann's
baby after birth?

A. If his abdominal wall appears to be ruptured

B. If his arms feel warm and are the same length

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 C. If his buttocks or back have extensive bruising
D. If his eyes can focus steadily on a nearby object

C. The research results revealed an increase in shoulder dystocia, which can result in diaphragmatic paralysis. Because this affects breathing, it is the nurse's primary
assessment taken after the birth.

- MJ