6. A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?
Correct Answer: B
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Successful rupture of membranes most commonly is determined by the immediate return of amniotic fluid from the vagina. This fluid usually is clear and odorless.
Option A: Fetal heart tones of 160 indicate tachycardia. Monitoring of the fetal heart rate as well as uterine activity can be easily obtained via external monitoring systems. However, in certain circumstances, more direct evaluation of the fetal heart rate or uterine activity is required during labor.
Option C: Greenish fluid is indicative of meconium. In certain circumstances, the fluid may either contain meconium or may be blood-tinged. It is important to note the color of the fluid at the time of rupture.
Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately. Typically, following artificial rupture of membranes, the practitioner should not immediately remove their hand from the vagina because it is at this point that the highest risk of potential cord prolapse can occur and will be noted as the amniotic fluid continues to drain. After the immediate flow of amniotic fluid ceases, and there is no palpable cord in the vagina, the vaginal hand then can be removed.
7. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
Correct Answer: D
Dilation of 2 cm marks the end of the latent phase of labor. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women respectively, without being considered prolonged.
Option A: This is a vague answer. The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. Cervical effacement refers to the cervical length in the anterior-posterior plane. When the cervix is completely thinned out and no length is left, this is referred to as 100 percent effacement.
Option B: This indicates the end of the first stage of labor. The first stage of labor begins when labor starts and ends with full cervical dilation to 10 centimeters. Labor often begins spontaneously or may be induced medically for a variety of maternal or fetal indications.
Option C: This indicates the transition phase. The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts.
8. The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:
Correct Answer: B
The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. A slow heart rate, or bradycardia, may indicate the baby is not getting enough oxygen delivery to the brain. A fast heart rate, or tachycardia, may indicate oxygen deprivation. There is an acceptable range of acceleration and deceleration – or speeding up and slowing down – of fetal heart rates during contractions and labor.
Option A: Repositioning the monitor is not indicated at this time. Obstetricians and nurses must carefully review fetal monitor strips throughout labor and delivery to ensure fetal heart tones are reassuring and the baby is getting enough oxygen. If non-reassuring conditions occur, appropriate and timely actions must be taken.
Option C: Asking the client to ambulate is not the best action for clients experiencing bradycardia. Generally, nursing interventions are attempted first to restore normal oxygenation to the baby. These include the administration of supplemental oxygen, changes in maternal position, increasing intravenous fluids, and the administration of medications that subdue contractions and maximize placental blood flow.
Option D: There is no data to indicate the need to move the client to the delivery room at this time. If fetal heart tones remain non-reassuring despite nursing interventions, the fetus should be delivered by emergency cesarean section. Emergency cesarean section should be performed within 5 to 30 minutes depending on the circumstances.
9. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
Correct Answer: D
The expected effect of Pitocin is cervical dilation. Oxytocin is indicated and approved by the FDA for two specific time frames in the obstetric world: antepartum and postpartum. In the antepartum period, exogenous oxytocin is FDA-approved for strengthening uterine contractions with the aim of successful vaginal delivery of the fetus.
Option A: Pitocin causes more intense contractions, which can increase the pain. When oxytocin is released, it stimulates uterine contractions, and these uterine contractions, in turn, cause more oxytocin to be released; this is what causes the increase in both the intensity and frequency of contractions and enables a mother to carry out vaginal delivery completely.
Option B: Cervical effacement is caused by pressure on the presenting part. During the later stages of pregnancy, the fetus’s head drops into the pelvis, pushing it against the cervix. This process stretches the cervix, causing it to thin and shorten. Measurement of effacement is usually in percentages. For example, when the cervix is 100% effaced, it means that it is completely thinned and shortened.
Option C: Infrequent contractions is opposite the action of Pitocin. Exogenous oxytocin causes the same response in the female reproductive system as that of endogenous oxytocin. Both types of oxytocin stimulate uterine contractions in the myometrium by causing G-protein coupled receptors to stimulate a rise in intracellular calcium in uterine myofibrils.
10. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
Correct Answer: B
Applying a fetal heart monitor is the correct action at this time. Fetal heart sounds are heard high in the abdomen in breech presentation. Be certain to monitor the FHR and uterine contractions continuously to detect fetal distress early and provide prompt intervention.
Option A: In a breech birth, the birth of the head is the most dangerous part because a loop of umbilical cord that has passed down alongside the head may be compressed. Intracranial hemorrhage is another danger of breech birth because of the pressure changes that has occurred spontaneously. There is no need to prepare for a Caesarean section because vaginal delivery is still possible.
Option C: It is unnecessary to place the client in Genupectoral position (knee-chest). An infant born from a frank breech position usually extends his or her legs continuously during the first 2 or 3 days of life, so be sure to point out to the parents that this is normal.
Option D: There is no need for an ultrasound based on the finding. An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia.