Nursing Care of Women with Complications During Labor and Birth (Chapter 08)

1.What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8° C. ANS: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise. DIF: Cognitive Level: Application REF: Page 176 OBJ: 3 TOP: Obstetric Procedures—Amniotomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2.A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse’s initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask. ANS: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur. DIF: Cognitive Level: Application REF: Page 177 TOP: Obstetric Procedures—Induction of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OBJ: 3 3.What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema ANS: B Ice is applied to the perineum to reduce bruising and edema. DIF: Cognitive Level: Application REF: Page 180 OBJ: 3 TOP: Obstetric Procedures—Lacerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4.After several hours of labor, a nursing assessment reveals that a woman’s cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal