Question 1

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client?

Accepted Answer

Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for disseminated intravascular coagulation (DIC). Thromboplastin from the retained dead fetus activates the clotting cascade, followed by consumption of clotting factors and platelets that leads quickly to life-threatening external and internal bleeding. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (eg, petechiae, ecchymosis), and organ damage from blood clotting (eg, respiratory distress, renal failure). Baseline laboratory tests (eg, coagulation studies, platelets, fibrinogen) and physical assessment for signs of DIC are a priority for at-risk clients because clotting and bleeding are often sudden and life-threatening (Option C). (Option A) The nurse applies a tocodynamometer ("toco") to monitor for contractions that may begin prior to oxytocin administration, but this is not a priority over laboratory assessment for DIC. (Option B) The nurse offers chaplain services and emotional support to clients and families experiencing pregnancy loss, but this is not the priority action. (Option D) A hemodynamically stable client with fetal demise should have labor induced as quickly as possible to prevent DIC, but this does not take priority over initial laboratory assessment. Educational objective: Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for developing disseminated intravascular coagulation (DIC). DIC can progress quickly; therefore, the nurse should prioritize assessment for any signs of DIC (eg, abnormal laboratory tests [coagulation studies, fibrinogen, platelets], signs of bleeding) before performing other interventions.

Question 2

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.

Accepted Answer

During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal (Option A). A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute (Option C). Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks (Option E). (Option B) A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life. (Option D) A single transverse crease extending across the palm of the hand is a classic sign of Down syndrome (an extra copy of chromosome 21). Other signs include small and low-set ears, flat nose bridge, protruding tongue, and hypotonia. Educational objective: Expected findings for a neonate at 1-3 hours postpartum include respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 mg/dL (3.9-5.6 mmol/L) but ≥40 mg/dL (2.2 mmol/L).

Question 3

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.

Accepted Answer

11ecbb05_cc0f_a326_b433_2fe89fa3f443_MD0009_00 Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. Shoulder dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When shoulder dystocia occurs, the primary nursing interventions include: Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) (Option B) Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed") Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) (Option C) Requesting additional help from staff (eg, nurses, neonatologist) immediately (Option E) (Options A and D) Fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicated because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications (eg, brachial plexus injury) in the newborn. Educational objective: Shoulder dystocia occurs when the anterior shoulder becomes wedged behind or under the maternal symphysis pubis. The nurse should document the timing of events (eg, birth of fetal head), verbalize passing time, perform McRoberts maneuver, apply suprapubic pressure, and request additional assistance.

Question 4

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply.

Accepted Answer

11ecbb05_cc0d_ce5f_b433_d97f1ae66a4f_MD0009_00 True labor is defined as contractions that cause progressive cervical change over time. Probable signs of labor are identified by assessing the timing and intensity of contractions, the success of comfort measures in relieving the pain, and the location of the pain (Options B and E). Consistent, intense contractions that get stronger and closer together (more frequent over time) and are associated with lower back discomfort that radiates to the abdomen are indicative of true labor (Options A and D). If a woman is experiencing Braxton Hicks contractions (ie, "false labor"), the nurse should provide encouragement and education about signs of labor and suggest comfort measures. Comfort measures relieve maternal anxiety, increase coping, and encourage normal progression of labor. The nurse may suggest walking, taking a warm bath, resting in a lateral position, having a snack, staying hydrated, and voiding often. (Option C) During pregnancy, a collection of secretions forms a "mucous plug" in the cervical canal, acting as a protective barrier. Although the client may notice expulsion of the mucous plug in the days preceding labor, it is not necessarily a sign of labor. Educational objective: True labor is defined as contractions that cause progressive cervical change over time. Consistent, intense contractions that get stronger and closer together and are associated with lower back discomfort that radiates to the abdomen are indicative of probable labor.

Question 5

A laboring client reports feeling the need to have a bowel movement and begins vomiting.  The nurse notes that the client's legs are trembling.  What cervical examination finding would the nurse most expect this client to have?

Accepted Answer

11ecbb05_cc0c_47bc_b433_4d064662f6bb_MD0009_00 The end of the first stage of labor (8-10 cm dilation) is commonly referred to as the "transition phase" of labor. This period is often characterized by perineal/rectal pressure due to fetal descent, which the client may perceive as an urge to have a bowel movement. The maternal ischial spines are designated as the "0 station" landmark. During this period, descent of fetal station below the maternal ischial spines (ie, +1 station or greater) often results in nausea and vomiting and trembling or shivering (Option D). Other maternal signs of the end of the first stage include increased pain, fear, irritability, anxiety, and self-doubt in the ability to birth. The client may require more assertive direction and emotional support during this period. (Option A) Cervical dilation of 0-5 cm denotes the early/latent phase of labor. During this phase, pain is usually well managed. Although possibly apprehensive, the client is usually able to maintain focus and follow directions. For these reasons, the latent phase is the best time to provide client education. (Options B and C) Cervical dilation of 6-7 cm denotes the start of the active phase of labor. During this period, apprehension and pain increase, and the ability to follow instruction decreases. The client's demeanor is more serious. Pain management, reassurance, and encouragement are priorities. Educational objective: Signs of the end of the first stage of labor ("transition phase") include perineal/rectal pressure, nausea and vomiting, trembling/shivering, increased pain, fear, irritability, and self-doubt. Laboring clients may require more assertive direction and additional emotional support during this period.

Question 6

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation.  The client is requesting IV pain medication.  When administering an IV narcotic during labor, which nursing action is appropriate?

Accepted Answer

Administration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth (Option B). Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief. (Option A) There is no reason to discontinue oxytocin prior to IV administration of pain medication. However, IV push medications should not be given through IV lines already infusing medication. (Option C) Narcotics do not typically inhibit contraction patterns or labor progress when labor is well established (ie, contractions every 2-5 minutes). However, it is inappropriate to withhold pain medication simply because the frequency of contractions is inadequate. For some clients, IV narcotics are used to provide pain relief and promote rest when latent labor is prolonged. (Option D) Narcotics given by IV push may be diluted according to manufacturer directions so that they can be more easily pushed over the recommended administration interval. Diluent should never be obtained from the IV bag or tubing due to the risk of inadvertently adding medication to IV fluids. Educational objective: IV narcotics administered to laboring women can cause fetal sedation and subsequent respiratory depression at birth. Administering IV narcotics at the peak of contractions reduces the amount of narcotic that crosses the placental barrier and affects the fetus.

Question 7

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client?

Accepted Answer

11ecbb05_cc0b_d28b_b433_efc364c083bc_MD0009_00 Developing cultural competence (ie, understanding, attitudes, and abilities acquired to meet the needs of culturally diverse clients) helps the nurse provide culturally sensitive labor support and pain management. Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication. It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management. In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping (Option C). Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief. (Option A) Pain assessments using a numeric pain scale do not adequately assess coping during labor. Furthermore, the appropriate frequency of pain assessments varies and may be influenced by labor progress and the client's preferred pain-relief method. (Options B and D) Stoicism and lack of outward expressions of pain do not indicate that the client is not experiencing pain, nor should they be misidentified as ineffective coping. Educational objective: A client's cultural background may affect expression of pain during labor. In Japanese culture, silence and nonverbal communication may be valued over overt forms of communication. The nurse should assess the client's coping and monitor for nonverbal cues of ineffective coping (eg, writhing, screaming, panicking).

Question 8

What is an appropriate nursing intervention after the birth of a newborn with anencephaly?

Accepted Answer

11ecbb05_cc0a_c11a_b433_f7a20f7c60c8_MD0009_00 Anencephaly is a severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero. Many newborns with anencephaly are stillborn, and those born alive are not compatible with life. Comfort care for the newborn and emotional support for the family is priority at the time of birth. Drying, bundling, and placing the newborn skin-to-skin provides warmth, and administering oxygen may decrease discomfort to the newborn. Allowing the family to hold the newborn will assist with the grieving process. (Option A) The nurse should ensure the family's privacy but should also consider the parents' preferences, as they may benefit from the support of friends and family, a religious leader, or a hospital chaplain. (Option B) Information about future genetic and preconception counseling is important discharge teaching as NTDs may be related to both genetic and environmental (eg, folic acid deficiency) factors. However, this intervention is not appropriate at this time. (Option C) The parents may benefit from a perinatal loss support group, and this referral should be made prior to discharge. However, immediately after birth is probably not the most appropriate time to provide information about this resource. Educational objective: Anencephaly is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. The newborn may be stillborn or born alive, although death occurs shortly thereafter. Nurses should facilitate a therapeutic environment for grieving parents and provide newborn comfort care such as warmth and oxygen.

Question 9

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation.  When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene?

Accepted Answer

Newborns whose mothers have diabetes mellitus are at increased risk for complications after birth, most commonly hypoglycemia but also hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. During intrauterine life, exposure to elevated maternal glucose levels causes the fetus to produce high levels of insulin. After birth, the newborn loses the maternal supply of glucose but continues to produce high levels of insulin, as during intrauterine life, increasing the risk of hypoglycemia (ie, blood glucose <40-45 mg/dL [2.2-2.5 mmol/L]). Symptoms of hypoglycemia, usually noted in the first several hours after birth, include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability. Immediate intervention is required to prevent neurologic damage (Option C). (Option A) Cyanosis of the hands and feet (acrocyanosis) is a benign, transient finding during the transition to extrauterine life. (Option B) The newborn's heart rate should be assessed by auscultation of the apical pulse for a full minute. A normal heart rate for a newborn is 110-160/min but may increase to 180/min during crying or may decrease to 100/min during sleep. (Option D) The newborn's respiratory pattern should be assessed for one full minute. Normal newborn respirations are 30-60/min and decrease to an average of 40/min after the transition period. Educational objective: Newborns whose mothers have diabetes mellitus are at increased risk for hypoglycemia, especially in the first several hours after birth. A common symptom of newborn hypoglycemia is jitteriness. Newborn hypoglycemia requires immediate intervention to prevent neurologic damage.

Question 10

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply.

Accepted Answer

Adoption, the decision to relinquish care of a child to another, is complex and involves a variety of emotional and psychosocial responses from clients. The nurse should encourage the birth mother to create memories with her newborn to facilitate the grieving process. This may include holding the newborn, taking pictures, and naming the newborn (Option B). When the time comes, offering the client a chance to say goodbye to the newborn supports the birth mother in her emotional transition and acknowledges the importance of her relationship with the newborn (Option D). The nurse protects the client by notifying relevant staff of the decision, which prevents unintended, potentially hurtful remarks (Option C). Substituting phrases like "giving up" and "giving away" with "choosing adoption" reinforce adoption as a loving decision and not neglect or abandonment (Option E). (Option A) Avoiding discussion of adoption details until after the birth inhibits the nurse's ability to plan care that respects the birth mother's wishes for interaction with the newborn and/or involvement of the adoptive parents in the birth process. Acknowledging the adoption plan early in the plan of care encourages the client to express emotions and be involved in decision-making. Educational objective: Caring for a client who plans to relinquish a newborn to an adoptive family involves giving the client an opportunity to express emotions, be involved in decision-making, interact with the newborn, make memories, and feel reassured that the decision is one of love and not abandonment.

Question 11

The nurse is reviewing several fetal heart rate (FHR) tracings for laboring clients at term gestation. Based on the FHR tracings, which client requires priority assessment by the nurse?

Accepted Answer

Uterine contractions during labor cause cervical dilation and effacement and promote fetal descent. During each contraction, compression of spiral arterioles (uterine vessels) normally decreases circulation in intervillous spaces, reducing placental blood flow. During resting intervals, reperfusion is restored between contractions to allow for fetal oxygenation. A healthy fetus easily tolerates this process. Uterine tachysystole occurs when contractions are too frequent (>5 in 10 minutes). It is sometimes associated with abnormal fetal heart rate (FHR) patterns because too-frequent contractions may cause inadequate reperfusion of the uterus and placenta due to shortened resting intervals between contractions. Unresolved uterine tachysystole may result in serious complications (eg, inadequate fetal oxygenation, placental abruption, uterine rupture) and warrants priority assessment and intervention by the nurse (eg, discontinuation of oxytocin, intrauterine resuscitation measures, tocolytics) (Option C). (Option A) Despite showing minimal variability, this FHR tracing does not require priority intervention over uterine tachysystole because accelerations indicate adequate fetal oxygenation at this time. Early decelerations indicate fetal head compression; they are not associated with poor outcomes, so the contraction pattern is not concerning. (Options B and D) FHR tracings with a normal frequency of contractions and FHR pattern (ie, category I) do not require priority assessment. Educational objective: Uterine tachysystole occurs when contractions are too frequent (>5 in 10 minutes), which may cause inadequate fetal oxygenation, placental abruption, or uterine rupture. This contraction pattern warrants priority assessment and intervention by the nurse to prevent maternal and fetal harm.

Question 12

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take?

Accepted Answer

Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part (Option A). If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access). (Option B) Large-bore IV access (ie, 18G or larger) is helpful for administrating oxytocin in the immediate postpartum period. However, the nurse first confirms that birth is not imminent before performing other actions. (Option C) Notifying the anesthesia provider would be appropriate after confirming that birth is not imminent and performing other nursing actions to ensure client and fetal well-being (eg, assessing fetal heart tones, initiating IV access). (Option D) The nurse should assess fetal heart tones and perform other interventions after determining that birth is not imminent. Educational objective: Precipitous birth is defined as <3 hours of labor from contraction onset until birth. When a client arrives at the hospital in second-stage labor, the nurse rapidly assesses whether birth is imminent before performing other interventions.

Question 13

The labor and delivery charge nurse receives report on several clients.  Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel?

Accepted Answer

11ecbb05_cc10_3f67_b433_35daff05199e_MD0009_00 Nurses must implement the five rights of delegation and understand the delegatee's scope of practice to ensure that tasks are appropriately delegated. Unlicensed assistive personnel (UAP) participate in client care by performing basic tasks (eg, hygiene, activities of daily living) for stable clients; tasks should have a predictable outcome and not require clinical judgment or assessment. five rights of delegation Repositioning an unmedicated, laboring client onto a birth ball is a low-risk, routine task that is appropriate to delegate to a UAP who has received proper training (Option D). In addition, the nurse should provide specific instructions to the UAP (eg, type of position, problems to report) and ensure appropriate completion of the task. (Option A) After a client gives birth with regional anesthesia (eg, epidural), the nurse must evaluate readiness for ambulation (eg, assess sensory and motor function) and observe early attempts to ambulate to ensure client safety. (Option B) The nurse is responsible for ongoing assessments of a client's health status in the triage setting. Therefore, the nurse should not delegate checking a perineal pad to the UAP if doing so may require assessment for leaking amniotic fluid. (Option C) Newborns require frequent monitoring (ie, vital signs) by nurses during the first several hours after birth, which is a vulnerable and potentially unstable time of transition to extrauterine life. Educational objective: Unlicensed assistive personnel may perform low-risk, routine tasks (eg, repositioning a stable, unmedicated client onto a birth ball) that have predictable outcomes and do not require clinical judgment or assessment.

Question 14

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor.  After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum.  Which action should the nurse anticipate?

Accepted Answer

11ecbb05_cc0e_dfd1_b433_9df64936c7bd_MD0009_00 Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder) (Option D). (Option A) Administering a tocolytic agent to stop contractions or relax the uterus is not recommended and does not resolve shoulder dystocia. (Option B) Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause uterine rupture. (Option C) Application of a vacuum extractor is contraindicated because it may further wedge the fetal shoulder into the symphysis pubis, increasing the risk for brachial plexus injury. Educational objective: Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure.

Question 15

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first?

Accepted Answer

An epidural block (a form of regional anesthesia) can provide effective pain relief during labor; however, it also inhibits the sympathetic nervous system (SNS). SNS inhibition causes peripheral vasodilation, which may produce significant hypotension (ie, systolic blood pressure <100 mm Hg, ≥20% decrease from baseline). If a client exhibits hypotensive symptoms (eg, lightheadedness, nausea) while receiving epidural anesthesia, the nurse should first assess blood pressure to confirm the presence of hypotension before intervening (Option C). If hypotension is present, initial nursing interventions include administering an IV fluid bolus to increase blood volume and positioning the client in the left lateral position to alleviate pressure on the vena cava. (Option A) IV ondansetron (Zofran) may help alleviate symptoms of nausea and vomiting, but evaluation and correction of potential hypotension should be completed first. (Option B) If hypotension persists after initial interventions or fetal distress occurs, further measures include administering IV vasopressors (eg, phenylephrine, ephedrine) and applying 8-10 L/min oxygen via face mask to increase blood flow and oxygen delivery to the fetus. (Option D) Nausea may occur independently of hypotension due to labor pain or as a sign of complete dilation. However, this client also has lightheadedness and is receiving epidural anesthesia; hypotension is extremely common with epidural anesthesia. Educational objective: Epidural blocks can inhibit the sympathetic nervous system, causing peripheral vasodilation leading to hypotension. Hypotensive symptoms include lightheadedness and nausea. The nurse should first assess blood pressure and then intervene (eg, IV fluids, left lateral positioning, oxygen) as appropriate.

Question 16

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply.

Accepted Answer

The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. (Option A) The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks. (Option C) Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system. Educational objective: Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls.

Question 17

The nurse is verifying the medical history of a client who is admitted for a scheduled labor induction.  Which client statement should prompt the nurse to request further evaluation for a primary cesarean birth from the health care provider?

Accepted Answer

Genital herpes, an incurable sexually transmitted infection caused by herpes simplex virus (HSV), is characterized by painful, vesicular lesions that form ulcers that crust over. Clients with a history of genital herpes are prescribed antivirals (eg, acyclovir) around 36 weeks gestation to prevent outbreaks prior to labor. Clients with active genital herpes infections (eg, lesions) or prodromal symptoms (eg, pain, burning, tingling) require a cesarean birth to prevent transmission to the fetus (ie, neonatal HSV infection). The nurse should notify the health care provider of the client's symptoms and request further evaluation to help facilitate an appropriate plan of care (eg, cesarean birth) (Option C). (Option A) Often, the use of a vacuum or forceps during birth is due to factors that do not influence future births (eg, abnormal fetal heart rate, maternal exhaustion). Therefore, a history of a vacuum- or forceps-assisted birth is not an indication for cesarean birth in subsequent pregnancies. (Options B and D) Most cardiac diseases (eg, atrial septal defect) and a history of venous thrombus are not indications for cesarean birth; these conditions increase the risk of complications during and following a cesarean birth because of the blood loss and immobility associated with surgery. Educational objective: Clients with an active genital herpes infection or prodromal symptoms require further evaluation for a cesarean birth to prevent infection of the fetus. History of a vacuum-assisted birth, an asymptomatic atrial septal defect, and venous thrombus are not indications for cesarean birth.

Question 18

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion.  When describing interventions, which statement by the nurse indicates a need for further education?

Accepted Answer

11ecbb05_cc0e_6aa0_b433_6363e2b2a81c_MD0009_00 Uterine inversion is a rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock. Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider (HCP) is the first step in resolving the inversion and requires a soft, uncontracted uterus. Tocolytics (eg, terbutaline) or inhaled anesthetics may be needed to assist with uterine relaxation. Uterotonic medications (eg, oxytocin, carboprost) must be delayed or discontinued until after the HCP has corrected the inversion (ie, manual uterine replacement) (Option A). After uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding. (Option B) Initiating a second, large-bore (eg, 18-gauge) IV line is an important intervention that allows for adequate volume resuscitation (eg, fluids, blood products) as needed for hemorrhage. (Option C) Serial blood pressure monitoring (eg, every 3-5 min) helps the nurse assess for worsening hypovolemic shock. (Option D) If manual uterine replacement through the vagina is unsuccessful, emergency laparotomy (ie, replacement via abdominal incision) may be necessary; it is appropriate to notify surgical staff members who will be involved. Educational objective: Uterine inversion is a postbirth complication in which the uterine fundus collapses into the uterine cavity, resulting in sudden hemorrhage and hypovolemic shock. Initially, a soft, uncontracted uterus is needed to correct the inversion (ie, manual uterine replacement), and uterotonic administration (eg, oxytocin) is delayed until after the uterus is replaced.

Question 19

The graduate nurse (GN) is caring for a laboring client with epidural anesthesia.  After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion.  Which action by the GN requires the nurse preceptor to intervene?

Accepted Answer

11ecbb05_cc0c_95dd_b433_092e336633dc_MD0009_00 An operative vaginal birth uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor. Indications may be maternal (eg, exhaustion, cardiac or cerebrovascular disease) or fetal (eg, abnormal fetal heart rate, arrest of rotation). In a forceps-assisted birth, the health care provider (HCP) gently applies the blades to the sides of the fetal head and locks the handles in place. The HCP applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head. The nurse should never apply fundal pressure during an operative vaginal birth because it may cause uterine rupture (Option A). (Option B) To avoid bladder damage, the nurse should ensure that the client has an empty bladder (eg, catheterization) before the forceps are applied. (Option C) Documentation should reflect birth events accurately for legal purposes and be done in a timely fashion. Birth events can happen quickly, but noting the time when forceps or a vacuum extractor is applied is essential. (Option D) The nurse notifies the HCP when contractions are palpated so that downward/outward traction can be applied to the forceps or a vacuum extractor during the contraction, which helps facilitate the birth. Educational objective: In an operative vaginal birth, forceps or a vacuum extractor is used to shorten the second (pushing) stage of labor. The nurse ensures that the client's bladder is empty, monitors for contractions, and documents the time that forceps or a vacuum extractor was applied. Fundal pressure should never be applied during this procedure or labor/birth.

Question 20

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure?

Accepted Answer

11ecbb05_cc0d_0b0e_b433_996d41698c55_MD0009_00 A pudendal nerve block infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the health care provider. It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor (Option D). In clients without an epidural, pudendal blocks may be used in preparation for forceps-assisted birth or laceration repair. perineal pressure (Option A) An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. A multiparous client may give birth before the epidural can be administered or before the epidural takes adequate effect (20-30 minutes). (Option B) Some clients forgo pharmacological pain relief during labor and instead utilize nonpharmacological techniques (eg, hydrotherapy, relaxation breathing). However, this client specifically requests pain relief, and nonpharmacological techniques would likely be ineffective considering birth is imminent. (Option C) IV narcotics cross the placenta and can cause neonatal respiratory depression when administered close to birth. Therefore, these are not generally administered in the second stage of labor. Educational objective: A pudendal nerve block can provide pain relief for clients experiencing perineal pressure in the late second stage of labor. It may also be used in preparation for forceps-assisted birth or laceration repair in clients without an epidural. It does not provide relief of contraction pain.

Exam 6: Maternal & Newborn Health

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client?

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply.

A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have?

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate?

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client?

What is an appropriate nursing intervention after the birth of a newborn with anencephaly?

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene?

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply.

The nurse is reviewing several fetal heart rate (FHR) tracings for laboring clients at term gestation. Based on the FHR tracings, which client requires priority assessment by the nurse?

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take?

The labor and delivery charge nurse receives report on several clients. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel?

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate?

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first?

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply.

The nurse is verifying the medical history of a client who is admitted for a scheduled labor induction. Which client statement should prompt the nurse to request further evaluation for a primary cesarean birth from the health care provider?

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education?