Chapter 20: Labour and birth risk

Question 1

1. In planning for home care of a patient with preterm labour, the nurse needs to address which concern?
   a. Nursing assessments will be different from those done in the hospital setting.
   b. Restricted activity and medications will be necessary to prevent recurrence of
   preterm labour.
   c. Prolonged bedrest is not supported as an effective intervention.
   d. Home health care providers will be necessary.

Answer 1

ANS: C
Bedrest is not a benign intervention, and there is no evidence in the literature to support the effectiveness of this intervention in reducing preterm birth rates. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labour, but not in all patients. In addition, the plan of care is individualized to meet the needs of each patient. Many patients will receive home health nurse visits, but care is individualized for each patient.

Question 2

2. The nurse providing care for a patient with preterm labour on nifedipine (Adalat) would include which intervention to identify adverse effects of the medication?
   a. Assessing deep tendon reflexes (DTRs)
   b. Assessing for hypotension
   c. Assessing for bradycardia
   d. Assessing for hypoglycemia

Answer 2

ANS: B
Patients administered nifedipine (Adalat) need to be assessed for hypotension, as it is common with this medication. Assessing DTRs would not address these concerns. Nifedipine (Adalat) may cause tachycardia, not bradycardia. Hypoglycemia and depression of DTRs are not common adverse effects of this drug.

Question 3

3. In evaluating the effectiveness of magnesium sulphate for the treatment of preterm labour, what finding would alert the nurse to possible adverse effects?
   a. Urine output of 160 mL in 4 hours
   b. Deep tendon reflexes 2+ and no clonus
   c. Blood pressure of 80/46
   d. Gastrointestinal bleeding

Answer 3

ANS: C
Blood pressure of 80/46 would alert the nurse to possible adverse effects because magnesium sulphate can cause severe hypotension. GI bleeding is not an adverse effect of magnesium sulphate. Urine output of 160 mL in 4 hours and deep tendon reflexes 2+ with no clonus are normal findings.

Question 4

4. A patient in preterm labour at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. What is the purpose of this pharmacological treatment?
   a. It stimulates fetal surfactant production.
   b. It relaxes uterine smooth muscle by inhibiting prostaglandins.
   c. It suppresses uterine contractions.
   d. It maintains adequate maternal respiratory effort during magnesium sulphate
   therapy.

Answer 4

ANS: A
Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Indomethacin relaxes uterine smooth muscle by inhibiting prostaglandins, not betamethasone. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulphate therapy.

Question 5

5. A patient at 26 weeks of gestation is being assessed to determine whether they are experiencing preterm labour. What finding indicates that preterm labour is most likely occurring?
   a. Estriol is not found in maternal saliva.
   b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
   c. Fetal fibronectin is present in vaginal secretions.
   d. The cervix is effacing and dilated to 2 cm.

Answer 5

ANS: D
Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labour. Changes in the cervix accompanied by regular contractions indicate labour at any gestation. For preterm labour the time frame is between 20 and 37 weeks of gestation. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions before 35 weeks of gestation could predict preterm labour, but it is not as predictive as the cervical changes.

Question 6

6. A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 5 hours. The patient is crying and wants an epidural. What is the likely status of this patient’s labour?
   a. They are exhibiting hypotonic uterine dysfunction.
   b. They are experiencing a normal latent stage.
   c. They are exhibiting hypertonic uterine dysfunction.
   d. They are experiencing pelvic dystocia.

Answer 6

ANS: C
Patients who experience hypertonic uterine dysfunction often are anxious first-time mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. These contractions usually occur in the latent stage (cervical dilation of less than 5 cm) and are usually uncoordinated. The contraction pattern seen in this patient signifies hypertonic uterine activity. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes.

Question 7

7. A patient is having their first child. They have been in labour for 15 hours. Two hours ago, their vaginal examination revealed the cervix to be dilated to 6 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago, her vaginal examination indicated that there had been no change. What abnormal labour pattern is associated with this description?
   a. Primary prolonged latent phase
   b. Protracted active phase
   c. Primary arrest of active phase
   d. Protracted descent

Answer 7

ANS: C
With an arrest of the active phase, the progress of labour has stopped. This patient has not had any anticipated cervical change, indicating an arrest of labour. In the nulliparous patient, a prolonged latent phase typically would last over 20 hours. A protracted active phase, the first or second stage of labour, would be prolonged (slow dilation: <1.2 cm/hr in a nullipara and <1.5 cm/hr in a multipara). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labour.

Question 8

8. What finding should the nurse expect when evaluating the effectiveness of an oxytocin induction?
   a. Contractions lasting 80 to 90 seconds, 2 to 3 minutes apart.
   b. The intensity of contractions are palpated to be moderate.
   c. Labour to progress at least 2 cm/hr dilation.
   d. At least 80 mU/min of oxytocin will be needed to achieve cervical dilation.

Answer 8

ANS: A
The goal of induction of labour would be to produce contractions that occur every 2 to 3 minutes and last 80 to 90 seconds. The intensity of the contractions should be strong upon palpation. Cervical dilation of 1 cm/hr in the active phase of labour would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min every 30 minutes until the desired contraction pattern is achieved. Oxytocin 80 mU/min is much too high of a dose.

Question 9

9. In planning for an expected Caesarean birth for a patient who has given birth by Caesarean previously and who has a fetus in the transverse presentation, the nurse would include what information?
   a. Because this is a repeat procedure, the patient is at lower risk for complications.
   b. Review the preoperative and postoperative procedures.
   c. Recovery is quicker with a second or subsequent Caesarean birth.
   d. Preoperative teaching is not required as the patient has had a Caesarean birth in
   the past.

Answer 9

ANS: B
Reviewing the preoperative and postoperative procedures is the most appropriate information to provide to the patient. It is not accurate to tell the patient they are at the lowest risk for complications. Both maternal and fetal risks are associated with every Caesarean birth. Recovery is not quicker with a second or subsequent Caesarean birth, each one is individual. Physiological and psychological recovery from a Caesarean birth is multifactorial and individual to each patient each time. Preoperative teaching should always be performed, regardless of whether the patient has already had this procedure.

Question 10

10. For a patient at 42 weeks of gestation, which finding would require more assessment by the nurse?
    a. Fetal heart rate of 116 beats/min
    b. Cervix dilated 2 cm and 50% effaced
    c. Score of 8 on the biophysical profile
    d. One fetal movement noted in 1 hour of assessment by the mother

Answer 10

ANS: D
Self-care in a postterm pregnancy should include performing daily fetal movement counts. The mother should feel six fetal movements in 2 hours. Normal findings in a 42-week gestation include fetal heart rate of 116 beats/min, cervix dilated 20 cm and 50% effaced, and a score of 8 on the biophysical profile.

Question 11

11. A pregnant patient’s amniotic membranes rupture. Prolapsed cord is suspected. Which intervention would be the top priority?
    a. Place the patient in the knee–chest position.
    b. Cover the cord in sterile gauze soaked in saline.
    c. Prepare the patient for a Caesarean birth.
    d. Start oxygen by face mask.

Answer 11

ANS: A
The patient is assisted into a position (e.g., modified left lateral recumbent position, modified left prone recumbent position, Trendelenburg position, or the knee–chest position) in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked in saline, preparing the patient for a Caesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.

Question 12

12. Prostaglandin E2 gel has been ordered for a pregnant patient at 42 weeks of gestation. The nurse knows that this medication will be administered for which reason?
    a. It will enhance uteroplacental perfusion in an aging placenta.
    b. It will increase amniotic fluid volume.
    c. It will ripen the cervix in preparation for labour induction.
    d. It will stimulate the amniotic membranes to rupture.

Answer 12

ANS: C
It is accurate to state that prostaglandin E2 gel will be administered to ripen the cervix in preparation for labour induction. It is not administered to enhance uteroplacental perfusion in an aging placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.

Question 13

13. Which assessment is least likely to be associated with a breech presentation?
    a. Meconium-stained amniotic fluid
    b. Fetal heart tones heard at or above the maternal umbilicus
    c. Preterm labour and birth
    d. Postterm gestation

Answer 13

ANS: D
Postterm gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.

Question 14

14. While caring for a patient whose labour is being augmented with oxytocin, the nurse recognizes that which finding would indicate that the oxytocin should be discontinued immediately?
    a. Uterine contractions occurring every 8 to 10 minutes
    b. A fetal heart rate (FHR) of 180 with absence of variability
    c. The patient needing to void
    d. Rupture of the patient’s amniotic membranes

Answer 14

ANS: B
This FHR is abnormal. The oxytocin should be discontinued immediately, and the health care provider should be notified. The goal of oxytocin administration is to have uterine contractions every 2 to 3 minutes, lasting 80 to 90 seconds; therefore, uterine contractions occurring every 8 to 10 minutes is not a reason to stop the infusion. The patient needing to void is not an indication to discontinue the oxytocin induction immediately or to call the health care provider. Unless a change occurs in the FHR pattern that is abnormal or the patient experiences uterine contractions closer than 2 minutes in frequency, the oxytocin does not need to be discontinued. The health care provider should be notified if the patient’s membranes have ruptured.

Question 14

15. The nurse should know that which statement is accurate?
    a. The terms preterm birth and low birth weight can be used interchangeably.
    b. Preterm labour is defined as cervical changes and uterine contractions occurring
    between 20 and 37 weeks of pregnancy.
    c. Low birth weight is anything below 3500 g.
    d. Preterm birth accounts for 18% to 20% of all births.

Answer 14

ANS: B
Preterm labour is described as cervical changes and uterine contractions occurring between 20 and 37 weeks of gestation; after 37 weeks the fetus can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (37 weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything below 2500 g. In 2014, the overall preterm birth rate for Canada was 8.1%.

Question 15

16. What should the nurse be aware of for the care related to preterm labour?
    a. Because all patients must be considered at risk for preterm labour and prediction
    is so hit-and-miss, teaching pregnant patients the symptoms probably causes more
    harm through false alarms.
    b. Braxton Hicks contractions often signal the onset of preterm labour.
    c. Because preterm labour is likely to be the start of an extended labour, a patient
    with symptoms can wait several hours before contacting the primary caregiver.
    d. The diagnosis of preterm labour is based on gestational age, uterine activity, and
    progressive cervical change.

Answer 15

ANS: D
Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicate preterm labour. It is essential that nurses teach patients how to detect the early symptoms of preterm labour. Braxton Hicks contractions resemble preterm labour contractions, but they are not true labour. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labour is not necessarily long-term labour.

Question 16

17. What should the nurse be aware of in the use of tocolytic therapy to suppress uterine activity?
    a. The drugs can be given efficaciously up to the designated beginning of term at 37
    weeks.
    b. There are no important maternal (as opposed to fetal) contraindications.
    c. Its most important function is to afford the opportunity to administer antenatal
    glucocorticoids.
    d. If the patient develops pulmonary edema while on tocolytics, intravenous (IV)
    fluids should be given.

Answer 16

ANS: C
Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.

Question 17

18. What should the nurse be aware of with regard to dysfunctional labour?
    a. Patients who are underweight are more at risk.
    b. Patients experiencing precipitous labour often express feelings of disbelief about
    their labour.
    c. Hypertonic uterine dysfunction is more common than hypotonic dysfunction.
    d. Abnormal labour patterns are most common in older patients.

Answer 17

ANS: B
Precipitous labour lasts less than 3 hours, and patients experiencing precipitous labour often express feelings of disbelief that their labour began so fast and progressed so quickly. Short patients or patients more than 15 kg overweight are more at risk for dysfunctional labour. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labour patterns are more common in patients under 20 years of age.

Question 18

19. Which should the nurse be aware of with regard to induction of labour?
    a. It can be achieved by external and internal version techniques.
    b. It is also known as a trial of labour (TOL).
    c. It is always done for medical reasons.
    d. It is rated for inducibility by a Bishop score.

Answer 18

ANS: D
Induction of labour is likely to be more successful with a Bishop score of 7 or higher. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labour is the observance of a patient and her fetus for several hours of active labour to assess the safety of vaginal birth. Induced labour is not always done for medical reasons.

Question 19

20. What should the nurse be aware of with regard to the process of inducing labour?
    a. Ripening the cervix usually results in a decreased success rate for induction.
    b. Labour sometimes can be induced with balloon catheters or laminaria tents.
    c. Oxytocin is less expensive than prostaglandins and more effective but has greater
    health risks.
    d. Amniotomy can be used to make the cervix more favourable for labour.

Answer 19

ANS: B
Laminaria tents and balloon catheters are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labour. Prostaglandin E2 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labour only when the cervix is already ripe.

Question 20

21. What should the nurse be aware of with regard to the process of augmentation of labour?
    a. It is active management of labour instituted when the labour process is not
    satisfactory.
    b. It relies on more invasive methods when oxytocin and amniotomy have failed.
    c. It is a term used for a forceps-assisted birth.
    d. It uses vacuum cups to actively assist with the birth of the baby.

Answer 20

ANS: A
Augmentation is part of the active management of labour that stimulates uterine contractions after labour has started but is not progressing satisfactorily. For augmentation, amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods, are used. Forceps-assisted births and vacuum-assisted births come at the end of labour and are not part of augmentation.

Question 21

22. What should the nurse be aware of with regard to Caesarean birth when providing care to a patient in labour?
    a. Caesarean births are declining in frequency in the twenty-first century in Canada.
    b. A Caesarean birth is more likely to be done for convenience than for medical risk.
    c. A Caesarean is performed primarily to preserve life or health of the mother and
    her fetus.
    d. A Caesarean birth can be either elected or refused by patients as their absolute
    legal right.

Answer 21

ANS: C
The most common indications for Caesarean birth are danger to the health or life of the mother and her fetus related to labour and birth complications. Caesarean births are increasing in Canada in this century. Caesarean birth is more likely to be done for medical reasons than for convenience. In rare instances the refusal by a patient to have a Caesarean birth can be legally overturned.

Question 22

23. The exact cause of preterm labour is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labours. Select the type of infection that has not been linked to preterm births.
    a. Viral
    b. Periodontal
    c. Cervical
    d. Urinary tract

Answer 22

ANS: A
The infections that increase the risk of preterm labour and birth are all bacterial. They include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, it is important for the patient to participate in early, continual, and comprehensive prenatal care. Evidence has shown a link between periodontal infections and preterm labour. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent infection. Cervical infections of a bacterial nature have been linked to preterm labour and birth. The presence of urinary tract infections increases the risk of preterm labour and birth.

Question 23

24. Which of the following may occur after 37 weeks of gestation when a fetus is in a breech position?
    a. Preterm birth
    b. Preterm labour
    c. Fetal distress
    d. External cephalic version

Answer 23

ANS: D
External cephalic version is used in an attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth. This is done by a physician. It is typically performed as an elective procedure in a labour and birth setting of non-labouring patients at or near term to improve their chances of having a vaginal cephalic birth. Preterm labour and birth is before 37 weeks, not after. Breech presentation in and of itself does not cause fetal distress.

Question 24

25. The nurse practicing in a labour setting knows that the patient most at risk for uterine rupture is
    a. a gravida 3 who has had two low-segment transverse Caesarean births.
    b. a gravida 2 who had a low-segment vertical incision for delivery of a 4.5 kg
    infant.
    c. a gravida 5 who had two vaginal births and two Caesarean births.
    d. a gravida 4 who has had all Caesarean births.

Answer 24

ANS: D
The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine rupture.

Question 25

26. A maternal indication for the use of forceps is
    a. a wide pelvic outlet.
    b. maternal exhaustion.
    c. a history of rapid labours.
    d. failure to progress past 0 station.

Answer 25

ANS: B
A mother who is exhausted may be unable to assist with the expulsion of the fetus. The patient with a wide pelvic outlet will likely not require vacuum extraction. With a rapid birth, forceps birth is not usually necessary. A station of 0 is too high for a forceps birth

Question 26

27. The priority nursing intervention after an amniotomy should be to
    a. assess the colour of the amniotic fluid.
    b. change the patient’s gown.
    c. estimate the amount of amniotic fluid.
    d. assess the fetal heart rate

Answer 26

ANS: D
The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Secondary to FHR assessment, amniotic fluid amount, colour, odour, and consistency is assessed. Dry clothing is important for patient comfort; however, it is not the top priority.

Question 27

28. The priority nursing care associated with an oxytocin infusion is
    a. measuring urinary output.
    b. increasing infusion rate every 30 minutes.
    c. monitoring uterine response.
    d. evaluating cervical dilation.

Answer 27

ANS: C
Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse’s priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of oxytocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labour progression is the standard of care for all labour patients.

Question 28

29. Immediately after the forceps-assisted birth of an infant, the nurse should
    a. assess the newborn for signs of trauma.
    b. give the newborn prophylactic antibiotics.
    c. apply a cold pack to the newborn’s scalp.
    d. measure the circumference of the newborn’s head.

Answer 28

ANS: A
The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps birth. A cold pack would put the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment.

Question 29

30. Surgical, medical, or mechanical methods may be used for labour induction. Which technique is considered a mechanical method of induction?
    a. Amniotomy
    b. Intravenous oxytocin
    c. Transcervical catheter
    d. Vaginal insertion of prostaglandins

Answer 29

ANS: C
Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction. Other methods to expand and gradually dilate the cervix include hydroscopic dilators such as laminaria tents (made from desiccated seaweed), or Lamicel (contains magnesium sulfate). Amniotomy is a surgical method of augmentation and induction.
Intravenous oxytocin and insertion of prostaglandins are medical methods of induction.

Question 30

1. What assessments are likely to be associated with a breech presentation? (Select all that apply.)
   a. Meconium-stained amniotic fluid
   b. Fetal heart tones heard at or above the maternal umbilicus
   c. Preterm labour and birth
   d. Postterm gestation
   e. Polyhydramnios
   f. Normal amniotic fluid volume

Answer 30

ANS: A, B, C, E
Meconium-stained amniotic fluid is normal in a breech presentation. The fetal heart tones are heard at or above the maternal umbilicus. Postterm gestation is not likely to be seen with a breech presentation. Breech presentations often occur in preterm births. Polyhydramnios, rather than a normal amniotic fluid volume, is a contributor to breech presentation.

Question 31

2. Which increases a patient’s risk of experiencing dystocia? (Select all that apply.)
   a. Midplane contracture of the pelvis
   b. Compromised bearing-down efforts as a result of pain medication
   c. Small fetus
   d. Hypotonic uterine contractions
   e. Tall stature
   f. Uterine understimulation with oxytocin

Answer 31

ANS: A, B, D
Causes of dystocia include hypotonic, uncoordinated, or infrequent uterine contractions; ineffective maternal bearing-down efforts; and alterations in the pelvic structure, among other causes. A large fetus, rather than small fetus, increases the maternal risk of dystocia. Short stature rather than tall stature increases a patient’s risk of dystocia. Uterine overstimulation with oxytocin increases the patient’s risk of dystocia, not understimulation.

Question 32

3. Complications and risks associated with Caesarean births include (Select all that apply.)
   a. placental abruption.
   b. wound dehiscence.
   c. hemorrhage.
   d. urinary tract infections.
   e. fetal injuries.

Answer 32

ANS: B, C, D, E
Placental abruption and placenta previa are both indications for Caesarean birth and are not complications thereof. Wound dehiscence, hemorrhage, urinary tract infection, and fetal injuries are all possible complications and risks associated with birth by cesarean section

Question 33

4. Induction of labour is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse in the labour and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labour induction. These include (Select all that apply.)
   a. rupture of membranes at or near term.
   b. convenience of the patient or their physician.
   c. chorioamnionitis (inflammation of the amniotic sac).
   d. postterm pregnancy.
   e. fetal death.

Answer 33

ANS: A, C, D, E
These are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the patient or their provider are not recommended; however, they have become commonplace. Factors such as rapid labours and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective induction should not occur before 39 weeks’ completed gestation.