What is the priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord protruding from the vagina? Show Answer: 1 The fetus's life is in jeopardy and a cesarean birth must be performed immediately. The cord is never handled because it may go into spasm and block the fetal blood supply. Neither checking the fetal heart rate every 15 minutes nor starting oxygen at 10 L/min with a tight face mask is the priority; the client must be prepared for an emergency cesarean birth. A client's membranes rupture, and the nurse immediately detects the presence of a prolapsed umbilical cord. The nurse
alerts another nurse, who calls the primary healthcare provider. Place the following nursing interventions in the order in which they should be performed. Answer: The priority nursing intervention is to maintain perfusion to the cord by removing the presenting part that is compressing it. The Trendelenburg position will help keep the presenting part off the cord. Oxygen should be administered to the mother to promote optimal oxygenation to the mother and fetus. Evaluating the response to the interventions includes checking the fetal heart rate. The nurse
instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? Answer: 2 In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true. When reviewing the history of a client admitted in preterm labor during her thirtieth week of gestation, the nurse suspects a risk factor associated with this client's preterm labor. Which risk factor does the nurse suspect? Answer: 4 Infections, especially urinary tract infections, are a risk factor for preterm labor. The number of pregnancies is not a risk factor for preterm labor. An android-shaped pelvis is more likely to cause dystocia than preterm labor. Clients receiving anticonvulsant medications are not at an increased risk for preterm labor. A client who had tocolytic therapy for preterm labor is being discharged. Which instructions should the nurse
include in the teaching plan? Answer: 2 Although it has not been proven that bed rest limits preterm labor, it is often recommended. Activities are restricted to bathroom privileges and movement to a daytime resting area. Fluid intake should not be restricted; hydration should be maintained. Monitoring of the urinary protein level is included in the care of a client with preeclampsia, not preterm labor. Deep-breathing exercises have no influence on the development of preterm labor. A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. Which factor does the nurse suspect precipitated this preterm labor? Answer: 2 An incompetent cervix indicates a short cervix, cervical scarring from previous births, or cervical or uterine anomalies. It puts the client at risk for second-trimester spontaneous abortion. An android pelvis is more likely to cause dystocia than preterm labor. A woman who has had a previous preterm labor, not a primigravida, is at risk for recurrence. Clients with epilepsy who are taking antiseizure medications are at risk for perinatal mortality rather than preterm labor. A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time? Answer: 2 Labor is continuing, and promotion of the well-being of both client and fetus is the priority nursing care during this period. Reduction of anxiety associated with preterm labor, supportive communication with the client and her partner, and helping the family cope with the impending preterm birth each address just one aspect of this client's needs and must be dealt with in the context of the priority need. A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine
life? Answer: 1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4. A
nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if accelerations of the fetal heart rate occur with fetal movement, this probably indicates what? Answer: 1 Accelerations of the fetal heart rate with fetal movement indicate fetal well-being. Early decelerations are associated with fetal head compression. Late decelerations are associated with uteroplacental insufficiency. Variable decelerations are associated with cord compression. The nurse is caring for a woman who just had a positive contraction stress test (CST). Which complication of pregnancy is of most concern when there is a positive CST? Answer: 4 A positive CST indicates a compromised fetus during contractions, which is associated with uteroplacental insufficiency. Preeclampsia does not cause a positive CST. The CST is contraindicated in women with suspected placenta previa, because the contractions can cause bleeding and may stimulate the onset of true labor. A CST is contraindicated in a woman with the potential for preterm birth or a pregnancy of less than 33 weeks' gestation, because contractions may stimulate true labor. The nurse is caring for a high-risk pregnant client who has had a positive contraction stress test (CST). What would the nurse interpret the result to mean? Answer: 4 Late decelerations of the fetal heart rate with each contraction constitute a positive CST result, which indicates fetal compromise. A CST performed after a nonstress test, not before, is nonreactive or equivocal. A positive CST result does not dictate a cesarean birth; an expeditious vaginal birth may be attempted. These variations in the fetal heart rate are expected in a healthy fetus. The nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when the fetal heart rate shows what during contractions? Answer: 1 A fetus with a borderline cardiac reserve will demonstrate hypoxia by a decreased heart rate when there is minimal stress, making the CST result positive. Accelerations are not defined as early, late, or prolonged. These are nonuniform drops in fetal heart rate before, during, or after a contraction; variable decelerations during a CST do not make the test result positive. The nurse
places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly associated with late decelerations? Answer: 3 Late decelerations, suggestive of fetal hypoxia, occur in the setting of uteroplacental insufficiency. Head compression results in early decelerations; this finding is considered benign. Hypothyroidism is unrelated to late decelerations. Umbilical cord compression results in variable decelerations. A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90
seconds, followed by bradycardia, are observed on the monitoring strip. Which physiologic finding does the nurse suspect is the cause of this abrupt change? Answer: 2 This variable pattern with bradycardia is an ominous sign; it is indicative of a prolapsed cord, or cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidosis, not fetal heart rate changes, occurs with uteroplacental insufficiency. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia, not variable decelerations followed by bradycardia, are associated with uteroplacental insufficiency. The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions,
the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? Answer: 2 The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth. Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? Answer: 1 Hypotension is a common side effect of epidural anesthesia that results in decreased placental perfusion and late decelerations on the fetal monitor. The priority intervention is repositioning the client to relieve compression of the vena cava and increase venous return, which in turn increases placental perfusion. Administering oxygen and increasing the flow rate are correct interventions, but neither is the priority because these interventions would not be effective until compression of the vena cava has been relieved and placental perfusion increased. Assessing the maternal blood pressure for a systolic pressure below 100 mm Hg only provides data and does not correct the late deceleration. Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse determines that the
fetus is experiencing late decelerations. List the following nursing actions in order of priority. 1.Reposition client on her side. Repositioning the client to the side increases uterine blood flow, improves cardiac output, and takes the pressure exerted by the uterus off the vena cava. Increasing the delivery of fluids augments uterine blood flow and improves cardiac output. Reassessing the FHR pattern enables the nurse to determine whether the FHR has returned to a safe level without reflex late decelerations. Persistent late decelerations are a nonreassuring fetal sign; the healthcare provider should be informed. Documentation of interventions and client responses ensures that information is included in the client's legal clinical record and communicated to other care providers. A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable
decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? Answer: 1 Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure or to the oxytocin. Preparing the client for an immediate birth is premature; other nursing measures should be tried first. External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action? Answer: 4 The reading noted by the nurse represents early decelerations that occur with head compression during a contraction, with the fetal heart rate (FHR) returning to baseline at the end of the contraction. Head compression and cord compression are both common occurrences during a contraction; intervention is unnecessary if the FHR returns to baseline at the end of the contraction. The dorsal recumbent position will increase pressure on the vena cava and is contraindicated. The nurse is caring for a client in transitioning labor and notes an early deceleration on the fetal heart monitor. Which nursing intervention would be most appropriate at this time? Answer: 2 Early FHR decelerations, with onset before the peak of the contraction and low point at the peak of the contraction, are due to fetal head compression. This is a normal finding during the transition stage of labor as the head descends. A nurse is observing the electronic fetal monitor as a client in labor enters the second stage. The nurse identifies early decelerations of the fetal heart rate with a return to the baseline at the end
of each contraction. What does this fetal heart rate pattern usually indicate? Answer: 4 Early decelerations are expected occurrences as the fetal head passes through the birth canal; the fetal heart rate returns to baseline quickly, indicating fetal well-being. The data do not indicate that the mother has diabetes. Variable decelerations occur with umbilical cord compression, not prolapse. Maternal hypotension will cause late decelerations because of fetal hypoxia. The nurse is preparing a client in active labor for epidural anesthesia. Which prescribed intervention should the nurse initiate before the anesthesiologist initiates the epidural? Answer: 3 Epidural anesthesia blocks sympathetic nerves along with pain nerves, which may result in vasodilation and hypotension. Rapid infusion of a nondextrose IV solution, such as lactated Ringer or normal saline solution, before initiation of the block fills the vascular system to offset vasodilation. Preload quantities are at least 500 to 1000 mL, infused rapidly. Oxygen would only be warranted if a hypotensive episode were to occur after the epidural was administered. Naloxone reverses opioid-induced respiratory depression. With epidural anesthesia the effects on the fetus depend on how the woman responds rather than on direct drug effects. Naloxone, an opioid antagonist, would only be used if it was warranted and delivery was imminent. An oxytocin infusion would not be used unless the contractions became dysfunctional. While caring for a client in labor, the nurse notes that during a contraction there is a 15-beat-per-minute acceleration of the fetal heart rate above the baseline. What is the nurse's most appropriate action at his time? Answer: 3 Periodic accelerations are the most reassuring of fetal heart rate indicators, regardless of the cause. This increase in the fetal heart rate does not require intervention by the practitioner at this time. Turning the mother on her left side to increase venous return is done when a fetal heart rate deceleration occurs. This is not a fetal heart rate abnormality and does not require a specific amount of time for observation; if the interventions are effective, monitoring should continue as before. The nurse observes a laboring client's amniotic fluid and decides that it is the
expected color and consistency. Which finding supports this conclusion? Answer: 2 By 36 weeks' gestation, amniotic fluid should be pale yellow with small particles of vernix caseosa present. Dark amber-colored fluid suggests the presence of bilirubin, an ominous sign. Greenish-yellow fluid may indicate the presence of meconium and suggests fetal compromise. Cloudy fluid suggests the presence of purulent material. A client is admitted to the birthing unit in active labor. An amniotomy is performed by the healthcare provider. Which physiologic alteration does the nurse expect to
occur after the procedure? Answer: 3 Amniotomy permits more effective pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Discomfort may increase because contractions usually become more intense after amniotomy. Amniotomy should not affect maternal and fetal heart rates. What is the priority nursing intervention for a laboring client with a sudden prolapse?The immediate priority is to minimize pressure on the cord. Thus the nurse's initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord.
What is the priority intervention when a cord prolapse has occurred?Umbilical cord prolapse is an acute obstetric emergency that requires immediate delivery of the baby. The route of delivery is usually by cesarean section. The doctor will relieve cord compression by manually elevating the fetal presentation part until cesarean section is performed.
What is the nursing care plan and intervention for a prolapsed umbilical cord?Once the cord has prolapsed and is exposed to air, drying of the umbilical cord and atrophy of the umbilical vessels would begin. Cover any exposed portion of the cord with a sterile saline compress to avoid drying. If there is already complete dilatation, the physician can deliver the baby to prevent fetal anoxia.
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What is the priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord protruding from the vagina?
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