OB Chapter 8 NCLEX ? – Flashcards
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Following an amniotomy, the nursing assessment that should be reported immediately is:
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Amniotic fluid is watery and pale green Rationale: Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.
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A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurse's initial action should be to:
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Stop the oxytocin infusion Rationale: Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.
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The nursing care of a woman with a third-degree laceration immediately after delivery would include:
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Cold pack to the perineum Rationale: Ice is applied to the perineum to reduce bruising and edema
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After several hours of labor, a nursing assessment reveals that a woman's cervix is 5 cm dilated but contractions are becoming shorter and less frequent. The nurse know that this labor pattern is described as:
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Hypotonic Rationale: The woman with hypotonic labor dysfunction begins labor normally, but contractions diminish after the active phase.
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When a hypotonic labor dysfunction occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will:
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Perform an amniotomy Rationale: Medical treatment for hypotonic labor dysfunction includes an amniotomy if the membranes are intact as the first remedy.
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The nurse would assess an infant delivered with the use of forceps for:
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Facial asymmetry Rationale: Pressure from forceps may injure the infant's facial nerve, which is evidenced by facial asymmetry.
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The new mother is distressed and tearful about the elevated dome over her baby's posterior fontanel. The nurse's best response is, "This condition will resolve itself in a few days. It is caused by:
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The effect of the vacuum extractor. Rationale: The "chignon" id due to the effect of the vacuum extractor and will disappear in a few days.
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The frustrated patient in hypotonic labor complains "My doctor won't induce my labor because of some silly Bishop score. He said I was a 4. What kind of magic number do I need?" The nurse explains that prior to induction the patient should be a Bishop score of at least:
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6 Rationale: The Bishop Score evaluated the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the ACOG.
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A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). To encourage fetal rotation and pain relief the nurse would position the patient?
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Sitting up and leaning forward on the over-bed table Rationale: 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
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The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman asks the nurse, "Please give me something." The most appropriate pain relief intervention for a woman in precipitate labor is to:
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Stay and breathe with her during contractions Rationale: 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.
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A woman who is 33 weeks pregnant is admitted to the obstetrical unit because her membranes ruptured spontaneously. She must be closely observed for signs of:
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Chorioamnionitis Rationale: 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
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The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect?
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Maternal tachycardia Rationale: Maternal tachycardia is the common negative side of terbutaline which should be corrected with a dose of propranolol.
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A student nurse questions the instructor as to what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. The best response is that the fundus of a patient with a cesarean section is:
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Gently assessed as usual Rationale: Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.
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A student nurse questions the instructor as to what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. The best response is that the fundus of a patient with a cesarean section is:
answer
Gently assessed as usual Rationale: Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.
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A pulsating structure is felt during a vaginal examination of a woman in labor. To prevent compression of a prolapsed cord, the nurse would position the woman:
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On her back with her head lower than the rest of her body Rationale: The Trendelenburg (head down) position displace the fetus upward to stop compression of the prolapsed cord.
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Several hours after delivery the nurse finds a woman crying. The woman say repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section." The most appropriate nursing diagnosis is:
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Grieving related to loss of expected birth experience. Rationale: Women who have cesarean birth usually need greater support than those having vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.
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A pregnant woman's membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. The nurse planning discharge instructions would teach the woman to:
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Notify her obstetrician for a temperature above 37.8 C. Rationale: For the woman with PROM who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8 C
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A woman who is 24 weeks pregnant is placed on an IV infusion of magnesium sulfate. The nurse should inform the patient that she might experience the side effect of this drug which is:
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Warm flush Rationale: Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.
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When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, anxious about the welfare of the baby, anxious about how quickly she will recover...in short, anxious about everything. The nurse is aware that anxiety can affect labor by:
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Reducing blood flow to the uterus Rationale: Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions
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During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae which seems to occur with every breath she takes. The nurse should:
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Notify the charge nurse immediately Rationale: Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. The should be immediately reported.
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The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last for 95 seconds, and the uterus remains tense between contractions. What action is expected on the basis of these assessments?
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Infusion of oxytocin will be stopped
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What is the appropriate nursing intervention during the early recovery period to increase the woman's comfort if she had a forceps-assisted birth and a median episiotomy?
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Application of a cold pack to her perineal area
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A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. She repeatedly asks similar questions about what happened at birth. The nurse's interpretation of the woman's behavior is that she:
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Is trying to understand her experience and move on with a postpartum adaptation
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What nursing intervention during labor can increase space in the woman's pelvis?
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Encourage regular urination
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A woman is being observed in the hospital because her membranes ruptured at 30 weeks of gestation. While giving morning care, the nursing student notices that draining fluid has a strong odor. The priority nursing action is to:
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Take the woman's temperature; report it and the fluid odor to the registered nurse.
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Following an amniotomy, the nursing assessment that should be reported immediately is:
answer
Amniotic fluid is watery and pale green
question
A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurse's initial action should be to:
answer
Stop the oxytocin infusion
question
The nursing care of a woman with a third-degree laceration immediately after delivery would include:
answer
Cold pack to the perineum
question
After several hours of labor, a nursing assessment reveals that a woman's cervix is 5 cm dilated but contractions are becoming shorter and less frequent. The nurse know that this labor pattern is described as
answer
Hypotonic
question
When a hypotonic labor dysfunction occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will:
answer
Perform an amniotomy
question
The nurse would assess an infant delivered with the use of forceps for:
answer
Facial asymmetry
question
The new mother is distressed and tearful about the elevated dome over her baby's posterior fontanel. The nurse's best response is, "This condition will resolve itself in a few days. It is caused by:
answer
The effect of the vacuum extractor
question
The frustrated patient in hypotonic labor complains "My doctor won't induce my labor because of some silly Bishop score. He said I was a 4. What kind of magic number do I need?" The nurse explains that prior to induction the patient should be a Bishop score of at least:
answer
6
question
A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). To encourage fetal rotation and pain relief the nurse would position the patient?
answer
Sitting up and leaning forward on the over-bed table
question
The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman asks the nurse, "Please give me something." The most appropriate pain relief intervention for a woman in precipitate labor is to:
answer
Stay and breathe with her during contraction
question
A woman who is 33 weeks pregnant is admitted to the obstetrical unit because her membranes ruptured spontaneously. She must be closely observed for signs of:
answer
Chorioamnionitis
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The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect?
answer
Maternal tachycardia
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The statement that indicates a woman understands activity limitations for the management of preterm labor is:
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"I have a picnic basket and put it next to the sofa so I do not have to get up for food during the day."
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A student nurse questions the instructor as to what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. The best response is that the fundus of a patient with a cesarean section is:
answer
Gently assessed as usual
question
A pulsating structure is felt during a vaginal examination of a woman in labor. To prevent compression of a prolapsed cord, the nurse would position the woman:
answer
On her back with her head lower than the rest of her body
question
Several hours after delivery the nurse finds a woman crying. The woman say repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section." The most appropriate nursing diagnosis is:
answer
Grieving related to loss of expected birth experience
question
A pregnant woman's membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. The nurse planning discharge instructions would teach the woman to:
answer
Notify her obstetrician for a temperature above 37.8 C
question
A woman who is 24 weeks pregnant is placed on an IV infusion of magnesium sulfate. The nurse should inform the patient that she might experience the side effect of this drug which is:
answer
Warm flush
question
When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, anxious about the welfare of the baby, anxious about how quickly she will recover...in short, anxious about everything. The nurse is aware that anxiety can affect labor by:
answer
Reducing blood flow to the uterus
question
During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae which seems to occur with every breath she takes. The nurse should:
answer
Notify the charge nurse immediately
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The obstetrician informs the nurse that the patient has a laceration that extends through the anal sphincter into the rectal mucosa. The nurse knows that this laceration is considered a:
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Fourth degree
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A woman in labor has excess amniotic fluid. She is in active labor and is not progressing because contractions are too weak to be effective. The nurse suspects this situation exists because of:
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decreased uterine muscle tone due to overdistention
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The principal goal of nursing care during labor is:
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promoting relaxation and helping the woman to conserve resources.
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Which are considered pharmacological methods to stimulate contractions? Select all that apply
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Prostaglandin gel Oxytocin administration
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A(n) ____________ incision is rarely used for cesarean birth because it involves more blood loss and is the most likely of the three types to rupture during another pregnancy.
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classic
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What is an amnioinfusion, and when is it indicated?
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Correct Answer(s): An amnioinfusion is the injection of warmed sterile saline or lactated Ringer's solution into the uterus via an intrauterine pressure catheter during labor after the membranes have ruptured. Indications for this procedure are oligohydramnios (a decrease in amniotic fluid), umbilical cord compression resulting in lack of amniotic fluid, reduction of recurrent variable decelerations in the fetal heart rate, and dilution of meconium-stained amniotic fluid.
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Summarize the indications for labor induction.
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Correct Answer(s): Indications for labor induction include gestational hypertension, ruptured membranes without spontaneous onset of labor, infection within the uterus, medical problems in the woman that worsen during pregnancy, fetal problems, placental insufficiency, and fetal death.
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Explain the use of oxytocin for induction or augmentation of labor.
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Correct Answer(s): Initiation or stimulation of contractions with oxytocin is the most common method of labor induction and augmentation. Oxytocin for induction or augmentation of labor is diluted in an intravenous (IV) solution. The oxytocin solution is a secondary infusion that is inserted into the primary IV solution line so it can be stopped quickly while an open IV line is maintained. The infusion of oxytocin is regulated with an infusion pump. Administration begins at a slow rate and is adjusted upward or downward. The dose is individualized for each woman. Continuous electronic monitoring is the usual method to assess and record fetal and maternal responses to oxytocin.
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What is version and what are the contraindications of this procedure?
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Correct Answer(s): Version is a method of changing the fetal presentation, usually from breech to cephalic. Contraindications include disproportion between the mother's pelvis and fetal size, abnormal uterine or pelvic size or shape, abnormal placental placement, previous cesarean birth with a vertical uterine incision, active herpesvirus infection, inadequate amniotic fluid, poor placental function, and multifetal gestation.
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List and describe the types of perineal lacerations and episiotomies.
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Correct Answer(s): First degree involves the superficial vaginal mucosa or perineal skin. Second degree involves the vaginal mucosa, perineal skin, and deeper tissues of the perineum. Third degree is the same as second degree but also involves the anal sphincter. Fourth degree extends through the anal sphincter into the rectal mucosa.
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Under what conditions are obstetric forceps and vacuum extractors used?
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Correct Answer(s): Obstetric forceps and vacuum extractors are used by an obstetrician to provide traction and rotation to the fetal head when the mother's pushing efforts are insufficient to accomplish a safe delivery.
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What conditions may indicate a cesarean delivery?
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Correct Answer(s): A cesarean delivery may be indicated by abnormal labor, inability of the fetus to pass through the mother's pelvis, maternal conditions such as gestational hypertension or diabetes, active maternal herpesvirus, previous surgery on the uterus, fetal compromise, and placenta previa or abruptio placentae.
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What is hypertonic labor, and how is it treated?
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Correct Answer(s): Hypertonic labor is characterized by contractions that are frequent, cramplike, and poorly coordinated. They are painful but nonproductive, and the uterus is tense even between contractions. Hypertonic labor may be treated with mild sedation, and tocolytic drugs such as terbutaline may be ordered.
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Identify the most common factors that can increase stress and cause dystocia during the labor process.
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Correct Answer(s): The most common factors that can increase stress and cause dystocia during the labor process are lack of analgesic control of excessive pain, absence of a support person or coach to assist with the nonpharmacological pain relief measures, immobility and restriction to bed, and a lack of ability to carry out cultural traditions.
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Describe the medical treatment for uterine inversion.
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Correct Answer(s): The physician will try to replace the inverted uterus while the woman is under general anesthesia. The anesthetic agent is chosen to cause uterine relaxation, and tocolytic drugs may be used. After the uterus is replaced, oxytocin is given to contract the uterus and control bleeding. If replacement is not successful, a hysterectomy may be performed.
