Old's Maternal-Newborn Nursing and Women's Health, 11th Edition | Chapter 23 Childbirth at Risk: Pre-labour Onset Complications

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Old's Maternal-Newborn Nursing and Women's Health, 11th Edition_Davidson/London/Ladewig) Chapter 23 Childbirth at Risk: Prelabor Onset Complications 1) A client is admitted to the labor and deli... very unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. What is this client at risk for? A) Gestational diabetes B) Placenta previa C) Abruptio placentae D) Placenta accreta Answer: C Explanation: A) Gestational diabetes is not an issue with this client. B) Placenta previa is not an issue with this client. C) Abruptio placentae is more frequent in pregnancies complicated by smoking, premature rupture of membranes, multiple gestation, advanced maternal age, cocaine use, chorioamnionitis, and hypertension. D) Placenta accreta is not an issue with this client. Page Ref: 565 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications. 2) The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? A) "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." B) "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." C) "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." D) "If I have amniocentesis, I might rupture the membranes again." Answer: C Explanation: A) Multifetal gestation increases the risk for PPROM. B) A urinary tract infection (UTI) increases the risk for PPROM. C) There is no evidence that bed rest in a subsequent pregnancy decreases the risk for PPROM. D) Amniocentesis increases the risk for PPROM. Page Ref: 562 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications. 3) A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect? A) Blood pressure B) Temperature C) Pulse D) Respiration Answer: B Explanation: A) Blood pressure can assist in the diagnosis of infection, but is not the primary vital sign. B) Rupture of membranes places the mother at risk for infection. The temperature is the primary and often the first indication of a problem. C) Pulse can assist in the diagnosis of infection, but is not the primary vital sign. D) Respirations can assist in the diagnosis of infection, but are not the primary sign. Page Ref: 561 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications. 4) The nurse admits into the labor area a client who is in preterm labor. What assessment finding would constitute a diagnosis of preterm labor? A) Cervical effacement of 30% or more B) Cervical change of 0.5 cm per hour C) 2 contractions in 30 minutes D) 8 contractions in 1 hour Answer: D Explanation: A) Cervical effacement of 80% or more would define preterm labor. B) A cervical change of at least 1 cm per hour would define preterm labor. C) Uterine contractions every 5 minutes for 20 minutes would define preterm labor. D) 8 contractions in a 60-minute period does define a diagnosis of preterm labor. Page Ref: 556 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Analyze the implications and maternal and fetal risks of preterm labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications. 5) During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be? A) To help the fetal head descend faster B) To use gravity and manipulation to relieve compression on the cord C) To facilitate dilation of the cervix with prostaglandin gel D) To prevent head compression Answer: B Explanation: A) The fetal head's descent would put additional pressure on the umbilical cord and reduce blood flow and oxygenation to the fetus. B) The top priority is to relieve compression on the umbilical cord to allow blood flow to reach the fetus. It is because some obstetric maneuvers to relieve cord compression are complicated that cesarean birth is sometimes necessary. C) Further dilatation of the cervix is unnecessary in light of a possible cesarean section. D) Head compression is not a concern in the case of prolapsed umbilical cord. The cord is what is compressed. Page Ref: 576 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications. 6) A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be? A) Perform a vaginal exam B) Notify the physician C) Place the client in a left lateral position D) Administer oxygen at 2 L per nasal cannula Answer: A Explanation: A) Prolapsed umbilical cord can occur when the membranes rupture. The fetus is more likely to experience variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord. A vaginal exam is the best way to confirm. B) A vaginal exam should be performed before the physician is notified. C) Positioning will not relieve the decreased heart rate if the cord is compromised. D) Oxygen will not relieve the decreased heart rate if the cord is compromised. Page Ref: 579, 581 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment - - - [Show More]

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