CH 22: Labor Related Problems

Question 139555
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139555
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MCSA
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:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
Placenta accreta
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.
Answer 1
false
Choice 2
Infection
Rationale 2
This patients 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.
Answer 2
false
Choice 3
Hypertensive crisis
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.
Answer 3
false
Choice 4
Amniotic fluid embolus
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.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Physiological Integrity
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Evaluation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO07_Q01
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Source Chapter Title:
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Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
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Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO07 - Summarize the identification, maternal and fetal-neonatal

implications, clinical therapy, and nursing care management of the woman
with an amniotic fluid embolus.
Question 139556
Id:
139556
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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 patients labor?
Stimulus
Answer
Choice 1
Cephalopelvic disproportion (CPD)
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.
Answer 1
true
Choice 2
Prolapsed cord
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).
Answer 2
false
Choice 3
Placenta accreta
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).
Answer 3
false
Choice 4
Occiput anterior (OA) fetal position
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).
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Assessment
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO03 _Q02

Source Au Title Ed:
Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO03 - Relate the various types of fetal malposition and malpresentation to

the nursing care management of each.
Question 139557
Id:
139557
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The nurse is making patient assignments for the next shift. Which patient is most likely to experience a
complicated labor pattern?
Stimulus
Answer
Choice 1
34-year-old gravida 6 at 39 weeks gestation with twins
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.
Answer 1
true
Choice 2
22-year-old gravida 1 at 23 weeks gestation with ruptured membranes
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.
Answer 2
false
Choice 3
30-year-old gravida 3 at 41 weeks gestation and estimated fetal weight 7

pounds, 8 ounces
Rationale 3
This patient has an average-sized fetus and no risk factors for either
hypertonic or hypotonic labor pattern development.
Answer 3
false
Choice 4
43-year-old gravida 2 at 37 weeks gestation with hypertension
Rationale 4
Hypertension does not impact labor pattern; this patient has no risk factors
for either hypertonic or hypotonic labor pattern development.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Health Promotion and Maintenance
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22 _LO01 _Q03

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO01 - Compare tachysystolic and hypotonic labor patterns, including risks,

clinical therapy, and nursing care management.
Question 139558
Id:
139558
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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 4050
seconds duration with intensity of 40 mmHg. The priority intervention would be:
Stimulus
Answer
Choice 1
Begin oxytocin after assessing for CPD.
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.
Answer 1
true
Choice 2
Give Terbutaline to stop the preterm labor.
Rationale 2
Terbutaline would not be recommended. The contraction pattern is

incoordinate, but they need to be enhanced, not stopped.
Answer 2
false
Choice 3
Start oxygen at 8 L/min.
Rationale 3
Oxygen will not hurt, but it is not the priority.
Answer 3
false
Choice 4
Have anesthesia give the patient an epidural.
Rationale 4
An epidural will not change the incoordinate contraction pattern.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22 LO01 Q04

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
admin
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

Question 139559
Id:
139559
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The primiparous patient is at 42 weeks gestation. What order should the nurse question?
Stimulus
Answer
Choice 1
Obtain biophysical profile today.
Rationale 1
A biophysical profile is a commonly used assessment for the post-term fetus.
Answer 1
false
Choice 2
Begin nonstress test now.
Rationale 2
The nonstress test is a commonly used assessment for the post-term fetus.
Answer 2
false
Choice 3
Schedule labor induction for tomorrow.
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.
Answer 3
false
Choice 4
Return to the clinic in one week.
Rationale 4
A post-term pregnancy is high-risk. Fetal assessments must be obtained to

verify fetal well-being or the need for delivery via induction or cesarean.
One week is too long a time period between assessments.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Implementation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
admin
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO02 - Describe the risks and clinical therapy in determining the nursing care
management of post-term pregnancy on the childbearing family.
Question 139560
Id:
139560
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The multiparous patient at term has arrived to the labor and delivery unit in active labor with intact
membranes. Leopolds maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What
physician order is most important?
Stimulus
Answer
Choice 1
Artificially rupture membranes.
Rationale 1
Artificial rupture of membranes is contraindicated with a transverse lie

because of the high risk for prolapsed cord.
Answer 1
false
Choice 2
Apply internal fetal scalp electrode.
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.
Answer 2
false
Choice 3
Monitor maternal blood pressure every 15 minutes.
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.
Answer 3
false
Choice 4
Alert the surgical team of urgent cesarean.
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.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO03_Q06

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

Question 139561
Id:
139561
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The nurse should anticipate the labor pattern for a fetal occiput posterior position to be:
Stimulus
Answer
Choice 1
Shorter than average during the latent phase.
Rationale 1
Overall labor is often prolonged, not shorter.
Answer 1
false
Choice 2
Prolonged with regard of the overall length of labor.
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.
Answer 2
true
Choice 3
Rapid during transition.
Rationale 3
Overall labor is often prolonged, not more rapid.
Answer 3
false
Choice 4
Precipitous.
Rationale 4
Overall labor is often prolonged, not precipitous.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22 LO03 Q07

Source Au Title Ed:
Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:

Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
Question 139562
Id:
139562
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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:
Stimulus
Answer
Choice 1
I am at risk for excessive bleeding after delivery.
Rationale 1
Because of the excessive size of the uterus with a macrosomic fetus, uterine
atony leading to postpartum hemorrhage is a risk.
Answer 1
false
Choice 2
His blood sugars could be high after he is born.
Rationale 2
Hypoglycemia, not hyperglycemia, is a potential complication experienced

by a macrosomic fetus.
Answer 2
true
Choice 3
My perineum could experience trauma during the birth.
Rationale 3
Perineal trauma due to the large fetus is a possible complication of vaginal

delivery of a macrosomic fetus.
Answer 3
false
Choice 4
His shoulders could get stuck and a collar bone broken.
Rationale 4
Shoulder dystocia is more common among large fetuses, and a broken

clavicle could result.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Evaluation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO04_Q08

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
admin
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO04 - Explain the identification, risks, and clinical therapy in determining

the nursing care management of the woman and fetus at risk for fetal
macrosomia.
Question 139563
Id:
139563
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The
fetal heart tones are 100105. Which nursing action is most important?
Stimulus
Answer
Choice 1
Change the mothers position from Fowlers to left lateral.
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.
Answer 1
true
Choice 2
Insert a Foley catheter with the assistance of another nurse.
Rationale 2
If a cesarean is needed, a Foley catheter will be needed. But at this time, this
is a low priority.
Answer 2
false
Choice 3
Notify the surgical team of an impending cesarean.
Rationale 3
The decision to go to cesarean birth is a medical decision. The nurse may not
make medical decisions.
Answer 3
false
Choice 4
Decrease the IV of lactated Ringers solution to 50 ml/hour.
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.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO05_Q09

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO05 - Relate the maternal implications, clinical therapy, prenatal history, and
conditions that may be associated with nonreassuring fetal status to the
nursing care of the mother and fetus.
Question 139564
Id:
139564
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
Assess the odor of the amniotic fluid.
Rationale 1
Although it is important to assess amniotic fluid for odors, checking the

cervix to assess for cord prolapse is a higher priority.
Answer 1
false
Choice 2
Perform Leopolds maneuver.
Rationale 2
This assessment is not called for at this time.
Answer 2
false
Choice 3
Obtain an order for pain medication.
Rationale 3
Pain medication is a low priority at this time.
Answer 3
false
Choice 4
Complete a sterile vaginal exam.
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.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Planning
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO06_Q10

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
admin
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO06 - Describe the nursing care for the mother and fetus with a prolapsed
umbilical cord.
Question 139565
Id:
139565
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The charge nurse is reviewing charting on patients in the maternalchild triage unit. Which entry requires
immediate intervention?
Stimulus
Answer
Choice 1
Primip at 24 weeks diagnosed with polyhydramnios: Patient reporting

shortness of breath.
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.
Answer 1
false
Choice 2
Multip at 32 weeks: Oligohydramnios per ultrasound secondary to fetal

renal agenesis.
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.
Answer 2
false
Choice 3
Primip at 41 weeks: Patient reports leaking clear fluid from her vagina for
seven hours.
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.
Answer 3
false
Choice 4
Multip at 34 weeks diagnosed with oligohydramnios: Cervix 6 cm, 2

station, up to walk in hallway.
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.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Source Au Title Ed:
Source Usage:
Chapter 22_LO07_Q11
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO07 - Summarize the identification, maternal and fetal-neonatal

implications, clinical therapy, and nursing care management of the woman
with an amniotic fluid embolus.
Question 139566
Id:
139566
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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:
Stimulus
Answer
Choice 1
Assist the patient to squat during the second stage.
Rationale 1
Squatting increases the diameter of the pelvic outlet and might facilitate
vaginal birth when cephalopelvic disproportion is a risk.
Answer 1
true
Choice 2
Encourage oral fluids and carbohydrate intake.
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.
Answer 2
false
Choice 3
Assess the cervix for change every eight hours.
Rationale 3
The cervix is normally assessed when the patients 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.
Answer 3
false
Choice 4
Inform the couple that labor might be prolonged.
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.

Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO08_Q12

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
admin
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO08 - Explain the types, maternal and fetal-neonatal implications, and

clinical therapy in determining the nursing care management of the woman
with cephalopelvic disproportion.
Question 139567
Id:
139567
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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:
Stimulus
Answer
Choice 1
Start an IV of lactated Ringers.
Rationale 1
The patient undergoing manual removal of the placenta will need either IV
sedation or general anesthesia. An IV is necessary.
Answer 1
true
Choice 2
Apply anti-embolism stockings.
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.
Answer 2
false
Choice 3
Bottle-feed the infant.
Rationale 3
The patients 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.
Answer 3
false
Choice 4
Send the placenta to pathology.
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.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO09_Q13

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
admin
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO09 - Identify common complications of the third and fourth stages of labor.
Question 139568
Id:
139568
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
Oxytocin administration
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.
Answer 1
false
Choice 2
Cesarean section
Rationale 2

Answer 2
true
Choice 3
Nipple stimulation
Rationale 3

Answer 3
false
Choice 4
Amniotomy
Rationale 4


Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Evaluating
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
admin
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

Question 139569
Id:
139569
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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:
Stimulus
Answer
Choice 1
Through your rectal mucosa.
Rationale 1
A fourth-degree laceration is through the rectal mucosa.
Answer 1
false
Choice 2
Up near your urethra.
Rationale 2
A periurethral laceration is near the urethra.
Answer 2
false
Choice 3
Into the muscle layer.
Rationale 3
A first-degree laceration involves only the skin. A second-degree laceration

involves skin and muscle.
Answer 3
false
Choice 4
Through your rectal sphincter.
Rationale 4
A third-degree laceration includes the rectal sphincter.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO09_Q15

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
admin
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO09 - Identify common complications of the third and fourth stages of labor.
Question 139570
Id:
139570
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What finding requires
immediate intervention?
Stimulus
Answer
Choice 1
Temperature 99.0F
Rationale 1
Women with intrauterine fetal demise can become infected, but this
temperature is not high enough to indicate infection.
Answer 1
false
Choice 2
Platelet count 210,000/cmm
Rationale 2
Intrauterine fetal demise can lead to disseminated intravascular coagulopathy

(DIC), but this is a normal platelet count.
Answer 2
false
Choice 3
Fibrinogen level 50 mg/dL
Rationale 3
Intrauterine fetal demise can cause disseminated intravascular coagulopathy

(DIC); the normal fibrinogen level is 200400 mg/dL. This is a very low
fibrinogen level and indicates that the patient is in DIC.
Answer 3
true
Choice 4
Family refusing fetal autopsy
Rationale 4
Some religious traditions prohibit autopsy. Disseminated intravascular

coagulopathy (DIC) is a higher priority.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 22_LO10_Q16

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO10 - Explain the etiology, diagnosis, and phases of grief in determining the
nursing care management of the family experiencing perinatal loss.

CH 22: Labor Related Problems

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CH 22: Labor Related Problems

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Question 139555

Amniotic fluid embolus

Client Need Sub:

Nursing Process: Evaluation

Source Chapter Number:

LO07 - Summarize the identification, maternal and fetal-neonatal

Cephalopelvic disproportion (CPD)

Occiput anterior (OA) fetal position

labor, slow cervical dilatation and effacement, and delayed engagement of

Client Need Sub:

Nursing Process: Assessment

Chapter 22_LO03 _Q02

Source Chapter Number:

Writer Last Name:

LO03 - Relate the various types of fetal malposition and malpresentation to

34-year-old gravida 6 at 39 weeks gestation with twins

22-year-old gravida 1 at 23 weeks gestation with ruptured membranes

Although this patient is high-risk, especially for infection, neonatal lung

30-year-old gravida 3 at 41 weeks gestation and estimated fetal weight 7

43-year-old gravida 2 at 37 weeks gestation with hypertension

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Assessment

Chapter 22 _LO01 _Q03

Source Chapter Number:

LO01 - Compare tachysystolic and hypotonic labor patterns, including risks,

Begin oxytocin after assessing for CPD.

The patient is having hypertonic contractions. The presence of CPD can

Give Terbutaline to stop the preterm labor.

Terbutaline would not be recommended. The contraction pattern is

Start oxygen at 8 L/min.

Oxygen will not hurt, but it is not the priority.

Have anesthesia give the patient an epidural.

An epidural will not change the incoordinate contraction pattern.

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Assessment

Chapter 22 LO01 Q04

Source Chapter Number:

LO01 - Compare tachysystolic and hypotonic labor patterns, including risks,

Obtain biophysical profile today.

A biophysical profile is a commonly used assessment for the post-term fetus.

Begin nonstress test now.

Schedule labor induction for tomorrow.

Labor induction is likely to occur with post-term pregnancies because the

Return to the clinic in one week.

A post-term pregnancy is high-risk. Fetal assessments must be obtained to

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Implementation

Chapter 22_LO02 _Q05

Source Chapter Number:

Artificially rupture membranes.

Artificial rupture of membranes is contraindicated with a transverse lie

Apply internal fetal scalp electrode.

An internal fetal scalp electrode cannot be applied until membranes have

Monitor maternal blood pressure every 15 minutes.

The fetus is at risk for hypoxia secondary to prolapsed cord if the

Alert the surgical team of urgent cesarean.

Client Need Sub:

Nursing Process: Implementation

Source Chapter Number:

LO03 - Relate the various types of fetal malposition and malpresentation to