Preview Extract
Chapter 22
1) A patient who sustained a difficult, lengthy labor and delivery is conversing with the
nurse. Suddenly, the patient complains of chest pain and appears dyspneic. She is cyanotic
and tachycardic, and her blood pressure has decreased to 78/36. What condition should the
nurse suspect is developing?
1. Placenta accreta
2. Infection
3. Hypertensive crisis
4. Amniotic fluid embolus
Answer: 4
Rationale 1:
Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium.
The major complications of placenta accreta include maternal hemorrhage and failure of the
placenta to separate following birth of the infant. Signs and symptoms of amniotic fluid
embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis.
Rationale 2:
This patient’s symptoms have a severe, sudden onset that is consistent with amniotic fluid
embolus. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea,
tachycardia, hypotension, and cyanosis.
Rationale 3:
The patient is hypotensive and is demonstrating signs and symptoms that are consistent with
amniotic fluid embolus, including chest pain, dyspnea, tachycardia, hypotension and
cyanosis.
Rationale 4:
Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia,
hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.
2) A 20-year-old woman who is pregnant with her first child has been laboring for 14 hours
with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is
unable to verify engagement of the presenting fetal part. What condition should the nurse
suspect may be affecting the patient’s labor?
1. Cephalopelvic disproportion (CPD)
2. Prolapsed cord
3. Placenta accreta
4. Occiput anterior (OA) fetal position
Answer: 1
Rationale 1:
The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement
are slow, and engagement of the presenting part is delayed.
Rationale 2:
A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal
bradycardia is a critical indicator of prolapsed cord. This patient is demsontrating prolonged
labor, slow cervical dilatation and effacement, and delayed engagement of the presenting
fetal part, which are consistent with cephalopelvic disproportion (CPD).
Rationale 3:
Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is
associated with maternal hemorrhage and failed placental separation after birth. This patient
is demonstrating prolonged labor, slow cervical dilatation and effacement, and delayed
engagement of the presenting fetal part, which are consistent with cephalopelvic
disproportion (CPD).
Rationale 4:
The occiput anterior (OA) fetal position is amenable to delivery and would not represent a
barrier to labor. This patient is demonstrating prolonged labor, slow cervical dilatation and
effacement, and delayed engagement of the presenting fetal part, which are consistent with
cephalopelvic disproportion (CPD).
3) The nurse is making patient assignments for the next shift. Which patient is most likely to
experience a complicated labor pattern?
1. 34-year-old gravida 6 at 39 weeks’ gestation with twins
2. 22-year-old gravida 1 at 23 weeks’ gestation with ruptured membranes
3. 30-year-old gravida 3 at 41 weeks’ gestation and estimated fetal weight 7 pounds, 8 ounces
4. 43-year-old gravida 2 at 37 weeks’ gestation with hypertension
Answer: 1
Rationale 1:
Twins at term will cause overdistention of the uterus, putting the patient at risk for
development of a hypotonic labor pattern. Her high parity also increases the risk for a
hypotonic labor pattern.
Rationale 2:
Although this patient is high-risk, especially for infection, neonatal lung immaturity, and
respiratory distress syndrome, this patient has no risk factors for an abnormal labor pattern.
Rationale 3:
This patient has an average-sized fetus and no risk factors for either hypertonic or hypotonic
labor pattern development.
Rationale 4:
Hypertension does not impact labor pattern; this patient has no risk factors for either
hypertonic or hypotonic labor pattern development.
4) Two hours ago, the 39-weeks’-gestation patient was 3 cm dilated, 40% effaced, and +1
station. Frequency of contractions was every five minutes with duration 40 seconds and
intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station.
Frequency of contractions is now every three minutes with 40–50 seconds’ duration with
intensity of 40 mmHg. The priority intervention would be:
1. Begin oxytocin after assessing for CPD.
2. Give Terbutaline to stop the preterm labor.
3. Start oxygen at 8 L/min.
4. Have anesthesia give the patient an epidural.
Answer: 1
Rationale 1:
The patient is having hypertonic contractions. The presence of CPD can prolong labor, so it is
important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by
strengthening the contractions.
Rationale 2:
Terbutaline would not be recommended. The contraction pattern is incoordinate, but they
need to be enhanced, not stopped.
Rationale 3:
Oxygen will not hurt, but it is not the priority.
Rationale 4:
An epidural will not change the incoordinate contraction pattern.
5) The primiparous patient is at 42 weeks’ gestation. What order should the nurse question?
1. Obtain biophysical profile today.
2. Begin nonstress test now.
3. Schedule labor induction for tomorrow.
4. Return to the clinic in one week.
Answer: 4
Rationale 1:
A biophysical profile is a commonly used assessment for the post-term fetus.
Rationale 2:
The nonstress test is a commonly used assessment for the post-term fetus.
Rationale 3:
Labor induction is likely to occur with post-term pregnancies because the aging placenta
becomes less efficient at transporting oxygen and nutrients and because the risk of fetal
macrosomia increases with length of gestation.
Rationale 4:
A post-term pregnancy is high-risk. Fetal assessments must be obtained to verify fetal wellbeing or the need for delivery via induction or cesarean. One week is too long a time period
between assessments.
6) The multiparous patient at term has arrived to the labor and delivery unit in active labor
with intact membranes. Leopold’s maneuver indicates the fetus is in a transverse lie with a
shoulder presentation. What physician order is most important?
1. Artificially rupture membranes.
2. Apply internal fetal scalp electrode.
3. Monitor maternal blood pressure every 15 minutes.
4. Alert the surgical team of urgent cesarean.
Answer: 4
Rationale 1:
Artificial rupture of membranes is contraindicated with a transverse lie because of the high
risk for prolapsed cord.
Rationale 2:
An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial
rupture of membranes is contraindicated with a transverse lie because of the high risk for
prolapsed cord.
Rationale 3:
The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The
maternal blood pressure is less important than getting the cesarean under way.
Rationale 4:
This is the highest priority because of the transverse lie and the risk of fetal hypoxia
secondary to prolapsed cord if the membranes rupture.
7) The nurse should anticipate the labor pattern for a fetal occiput posterior position to be:
1. Shorter than average during the latent phase.
2. Prolonged with regard of the overall length of labor.
3. Rapid during transition.
4. Precipitous.
Answer: 2
Rationale 1:
Overall labor is often prolonged, not shorter.
Rationale 2:
The malposition does not allow the smallest diameter of the fetal head to come down the birth
canal, and this can prolong the overall length of labor.
Rationale 3:
Overall labor is often prolonged, not more rapid.
Rationale 4:
Overall labor is often prolonged, not precipitous.
8) The patient has undergone an ultrasound, which estimated fetal weight at 4,500 g (9
pounds, 14 ounces). Which statement indicates that additional teaching is needed? “Because
my baby is big:
1. “I am at risk for excessive bleeding after delivery.”
2. “His blood sugars could be high after he is born.”
3. “My perineum could experience trauma during the birth.”
4. “His shoulders could get stuck and a collar bone broken.”
Answer: 2
Rationale 1:
Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to
postpartum hemorrhage is a risk.
Rationale 2:
Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic
fetus.
Rationale 3:
Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a
macrosomic fetus.
Rationale 4:
Shoulder dystocia is more common among large fetuses, and a broken clavicle could result.
9) The laboring patient has experienced spontaneous rupture of membranes. The fluid is
meconium-stained. The fetal heart tones are 100–105. Which nursing action is most
important?
1. Change the mother’s position from Fowler’s to left lateral.
2. Insert a Foley catheter with the assistance of another nurse.
3. Notify the surgical team of an impending cesarean.
4. Decrease the IV of lactated Ringer’s solution to 50 ml/hour.
Answer: 1
Rationale 1:
Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal
bradycardia is present. Left lateral position increases uterine blood flow.
Rationale 2:
If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority.
Rationale 3:
The decision to go to cesarean birth is a medical decision. The nurse may not make medical
decisions.
Rationale 4:
Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the patient is
hypotensive. Decreasing the IV rate will not improve fetal heart tones.
10) The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture
with a large amount of clear amniotic fluid. Which nursing action is most important to
undertake at this time?
1. Assess the odor of the amniotic fluid.
2. Perform Leopold’s maneuver.
3. Obtain an order for pain medication.
4. Complete a sterile vaginal exam.
Answer: 4
Rationale 1:
Although it is important to assess amniotic fluid for odors, checking the cervix to assess for
cord prolapse is a higher priority.
Rationale 2:
This assessment is not called for at this time.
Rationale 3:
Pain medication is a low priority at this time.
Rationale 4:
Checking the cervix will determine whether the cord prolapsed when the membranes
ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death
within minutes if not treated.
11) The charge nurse is reviewing charting on patients in the maternal–child triage unit.
Which entry requires immediate intervention?
1. Primip at 24 weeks diagnosed with polyhydramnios: “Patient reporting shortness of
breath.”
2. Multip at 32 weeks: “Oligohydramnios per ultrasound secondary to fetal renal agenesis.”
3. Primip at 41 weeks: “Patient reports leaking clear fluid from her vagina for seven hours.”
4. Multip at 34 weeks diagnosed with oligohydramnios: “Cervix 6 cm, −2 station, up to walk
in hallway.”
Answer: 4
Rationale 1:
Although this patient is uncomfortable, shortness of breath often accompanies
polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to
facilitate comfort, but this is not a life-threatening emergency.
Rationale 2:
Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production.
This patient will be grieving but is not experiencing physical complications.
Rationale 3:
Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios,
which in turn can lead to variable decelerations. This patient might be experiencing a
complication, but it is a lower priority than the patient with the possibility of a prolapsed
cord.
Rationale 4:
Active labor in a preterm multip with the presenting part high in the pelvis is at high risk for
prolapse of the cord when the membranes rupture. This patient should be on bed rest until the
membranes rupture and the presenting part has descended well into the pelvis. This patient is
at the highest risk for physical complication (cord prolapse) and therefore is the highest
priority.
12) The patient at term has a suspected small pelvis. The fetus has an estimated weight of
4,200 g (9 pounds, 4 ounces). Spontaneous labor has begun, and the patient is now at 6 cm.
The nurse understands that the most important nursing action for this patient is to:
1. Assist the patient to squat during the second stage.
2. Encourage oral fluids and carbohydrate intake.
3. Assess the cervix for change every eight hours.
4. Inform the couple that labor might be prolonged.
Answer: 1
Rationale 1:
Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when
cephalopelvic disproportion is a risk.
Rationale 2:
A patient with a large fetus and a small pelvis has a higher-than-average chance of needing a
cesarean. This patient should either be given only clear liquids or be n.p.o. to reduce the risk
of aspiration should a cesarean need to be performed.
Rationale 3:
The cervix is normally assessed when the patient’s labor status appears to have changed, or in
order to determine whether cervical change is taking place. The cervix would be assessed
more frequently if a patient was in the active phase of labor and cephalopelvic disproportion
was a risk. Every eight hours is too far apart.
Rationale 4:
Although it is true that labor with a large fetus and a small pelvis could be prolonged,
informing the couple of this fact is a psychosocial intervention. Physiologic interventions are
a higher priority.
13) The patient gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has
not yet delivered. Manual removal of the placenta is planned. The nurse should prepare to:
1. Start an IV of lactated Ringer’s.
2. Apply anti-embolism stockings.
3. Bottle-feed the infant.
4. Send the placenta to pathology.
Answer: 1
Rationale 1:
The patient undergoing manual removal of the placenta will need either IV sedation or
general anesthesia. An IV is necessary.
Rationale 2:
Anti-embolism stockings are used after major surgery that leads to immobility, thus
increasing the risk of embolism. However, anti-embolism stockings are not needed for this
patient because manual removal of the placenta is not major surgery and does not lead to
post-procedure immobility.
Rationale 3:
The patient’s partner or family member, or a nursery nurse, can feed the infant. The patient is
at risk for excessive blood loss due to retained placenta, and preparation for manual removal
of the placenta is a higher priority at this time.
Rationale 4:
The placenta might be sent to pathology after it is removed, but preparing the patient for
manual removal of the placenta now is a higher priority.
14) The nurse is caring for a laboring patient with known cephalopelvic disproportion (CPD).
The woman develops tachysystolic labor patterns. Which possible course of treatment should
the nurse anticipate?
1. Oxytocin administration
2. Cesarean section
3. Nipple stimulation
4. Amniotomy
Answer: 2
Rationale 1:
Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple
stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD),
a cesarean birth is indicated, as vaginal delivery cannot be performed.
Rationale 2:
Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple
stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD),
a cesarean birth is indicated, as vaginal delivery cannot be performed.
Rationale 3:
Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple
stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD),
a cesarean birth is indicated, as vaginal delivery cannot be performed.
Rationale 4:
Cesarean section is the most likely course of action. Oxytocin, amniotomy, and nipple
stimulation are all indicated for induction of labor. With cephalopelvic disproportion (CPD),
a cesarean birth is indicated, as vaginal delivery cannot be performed.
15) The patient has delivered a 4,200g fetus. The physician performed a midline episiotomy,
which extended into a third-degree laceration. The patient asks the nurse where she tore.
Which response is best? “The episiotomy extended and tore:
1. “Through your rectal mucosa.”
2. “Up near your urethra.”
3. “Into the muscle layer.”
4. “Through your rectal sphincter.”
Answer: 4
Rationale 1:
A fourth-degree laceration is through the rectal mucosa.
Rationale 2:
A periurethral laceration is near the urethra.
Rationale 3:
A first-degree laceration involves only the skin. A second-degree laceration involves skin and
muscle.
Rationale 4:
A third-degree laceration includes the rectal sphincter.
16) The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What
finding requires immediate intervention?
1. Temperature 99.0°F
2. Platelet count 210,000/cmm
3. Fibrinogen level 50 mg/dL
4. Family refusing fetal autopsy
Answer: 3
Rationale 1:
Women with intrauterine fetal demise can become infected, but this temperature is not high
enough to indicate infection.
Rationale 2:
Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this
is a normal platelet count.
Rationale 3:
Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the
normal fibrinogen level is 200–400 mg/dL. This is a very low fibrinogen level and indicates
that the patient is in DIC.
Rationale 4:
Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is
a higher priority.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
