Question 1 of 7
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Which order during labor augmentation would cause the nurse to question the health care provider?
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- Administer oxytocin in lactated Ringer solution per protocol.Solutions that contain electrolytes have been shown to decrease the risk for water intoxication when using oxytocin. Lactated Ringer contains electrolytes.
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- Administer oxytocin in normal saline per protocol.Solutions that contain electrolytes have been shown to decrease the risk for water intoxication. Normal saline contains sodium chloride.
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- Administer oxytocin in dextrose 10% per protocol.Using hypertonic solutions such as dextrose 10% increases the risk for water intoxication because it increases the antidiuretic effects of oxytocin.
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- Administer oxytocin in 10-minute pulsed infusions.Oxytocin may be given in 10-minute pulsed infusions rather than continuously.
Question 2 of 7
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A G1/P0 patient arrives for elective induction of labor at 39 weeks and is 1 to 2 cm dilated and 50% effaced. The fetal station is −3 with a posterior and firm cervix. Which order is most appropriate based on this patient’s Bishop score?
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- Discharge to home with follow-up in 1 week at the office.This patient has a very low Bishop score, is a primigravida, and is only at 39 weeks gestation. The most appropriate action would be to reevaluate in 1 week because her risk for cesarean delivery is increased based on her Bishop score.
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- Administer oxytocin and titrate per protocol.This patient would need cervical ripening before oxytocin administration if the health care provider determined the benefits of induction outweighed the risks.
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- Assist with amniotomy and initiate oxytocin as prescribed.Amniotomy is not indicated, and cervical ripening should be initiated before oxytocin administration.
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- Initiate electronic fetal monitoring and insert peripheral intravenous device.The most appropriate action would not be to continue to monitor the patient, because it is not medically indicated. The patient has a higher risk for cesarean delivery if induction of labor is initiated during this encounter.
Question 3 of 7
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While monitoring a patient receiving oxytocin for augmentation of labor, the nurse notes tachysystole with recurrent late decelerations and minimal variability on the electronic fetal monitor. Which actions are appropriate?
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- Discontinue the oxytocin infusion.Oxytocin infusion can cause tachysystole and decreased uteroplacental perfusion. It should be discontinued when fetal compromise is noted with tachysystole.
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- Reposition the patient on her side.Repositioning the patient on her side increases uteroplacental perfusion.
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- Administer an intravenous bolus of fluid per protocol.Administering a fluid bolus is part of the intrauterine resuscitation protocol and is an appropriate action.
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- Administer 100% oxygen via tight face mask.Administering oxygen is part of the intrauterine resuscitation protocol and is an appropriate action.
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- Notify the health care provider.The patient is experiencing a medical emergency, and the health care provider should be notified.
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- Place the patient in semi-Fowler position and continue to monitor.Semi-Fowler position can increase pressure on the vena cava, causing further uteroplacental/fetal compromise. Also, although continued monitoring is important, immediate interventions are required.
Question 4 of 7
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A woman in labor has been having regular contractions but has remained 5 cm dilated for 5 hours, with a reassuring fetal heart rate. Which intervention may be necessary for this patient?
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- Labor augmentationLabor augmentation may be necessary when labor progress has stopped or slowed.
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- Cesarean deliveryIf there is no fetal or maternal indication, cesarean delivery is not yet indicated.
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- Vacuum-assisted deliveryThe need for vacuum-assisted delivery cannot be determined at this point in this patient’s labor.
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- Intrauterine resuscitationIntrauterine resuscitation is only indicated with a nonreassuring fetal heart rate.
Question 5 of 7
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The nurse is caring for a patient in the second stage of labor. Which patient condition is most likely to result in the need for an episiotomy?
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- A patient with a history of perineal lacerationHistory of perineal laceration is not an indication for episiotomy because an earlier laceration does not mean that perineal tissues will be weakened in subsequent pregnancies.
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- A patient receiving oxytocin for induction of laborAn episiotomy would be indicated if the risk for perineal tear were present, but the administration of oxytocin does not necessarily increase this risk.
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- A patient whose fetus is experiencing shoulder dystociaShoulder dystocia is an indication for episiotomy because it is necessary to allow as much room as possible for the delivery of the shoulder.
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- A patient who had an episiotomy during a previous deliveryEach pregnancy is different, and conditions that might necessitate an episiotomy are not predictable on the basis of a previous history of episiotomy. An episiotomy would be indicated if the risk for a perineal tear were present, but this cannot be determined solely on the basis of a previous episiotomy.
Question 6 of 7
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The nurse is caring for a patient who had a forceps delivery that caused a perineal hematoma. Which nursing intervention is most appropriate?
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- Administer topical analgesic ointment as prescribed.Topical analgesics would have little therapeutic effect on the hematoma and any pain associated with it.
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- Provide the patient with an ice pack and educate her about its use.Ice packs can help relieve the pain of hematomas or lacerations after operative delivery by causing vasoconstriction and decreasing blood flow to the area, as well as decreasing edema. Patients should be guided toward use for the first 12 hours, followed by intermittent use.
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- Encourage the patient to lie on her side as much as possible until the injury heals.The nurse would encourage the patient to adopt a position that relieves pressure and pain. However, there is no reason to believe that side lying is more likely than other positions to relieve the patient’s pain.
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- Educate the patient about the fact that the hematoma was caused by the introduction of forceps.A hematoma is generally painful, and addressing this physiologic need is a priority over education about the cause.
Question 7 of 7
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The nurse is providing care for a patient in labor, and the health care provider has just stated the patient’s need for a forceps-assisted delivery. Which actions would the nurse’s preparation include?
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- Obtaining a urinary catheterThe patient’s bladder must be empty during an operative delivery. Use of an intermittent catheter is expected.
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- Establishing intravenous (IV) accessIf possible, IV access should be established for the patient who undergoes an operative vaginal delivery. This can provide a route for additional pain medication. It is also necessary if the forceps delivery fails and cesarean delivery is necessary. Delivery should not be delayed to obtain IV access.
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- Performing a head-to-toe assessmentAssessments during labor are prioritized according to the patient’s anticipated needs at that particular stage. Close monitoring is necessary before and during operative delivery, but a complete head-to-toe assessment is not necessary.
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- Educating the patient about the risk for lacerationsIt is not the nurse’s responsibility to explain the risks of an operative delivery to the patient, although the nurse would address any of the patient’s voiced concerns or questions. Explaining risks is the health care provider’s responsibility.
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- Preparing the forceps using aseptic techniqueWhen an operative vaginal delivery is indicated, the nurse is often responsible for assisting the health care provider by preparing necessary supplies.
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- Monitoring the fetal heart rate for signs of distressThe health care provider is occupied with the delivery, and the nurse is responsible for alerting the health care provider to signs of fetal distress during operative vaginal delivery.