Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours postpartum, PR= 80 bpm, fundus soft and boundaries not well defineD. The appropriate nursing diagnosis is:
-
Solution
Hemorrhage secondary to uterine atony
All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and boundaries not well defined, the cause of the hemorrhage could be uterine atony.
The fetal heart rate is checked following rupture of the bag of waters in order to:
-
Solution
Determine if cord compression followed the rupture
After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head.
Which of the following techniques during labor and delivery can lead to uterine inversion?
-
Solution
Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation
When the placenta is still attached to the uterine wall, tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached.
The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 centimeters. A repeat I.E. done at 10 A. M. showed that cervical dilation was 7 cm. The correct interpretation of this result is:
-
Solution
The active phase of Stage 1 is protracted
The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour. Since the time elapsed is already 2 hours, the dilatation is expected to be already 8 cm. Hence, the active phase is protracted.
When giving narcotic analgesics to mother in labor, the special consideration to follow is:
-
Solution
Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours.
Narcotic analgesics must be given when uterine contractions are already well established so that it will not cause stoppage of the contraction thus protracting labor. Also, it should be given when delivery of fetus is imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can pass through placental barrier.
The preferred manner of delivering the baby in a gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesiA. The main rationale for this is:
-
Solution
To make the delivery effort free and the mother does not need to push with contractions
Forceps delivery under epidural anesthesia will make the delivery process less painful and require less effort to push for the mother. Pushing requires more effort which a compromised heart may not be able to endure.
While assessing a G2P2 client who had a normal spontaneous vaginal delivery 30 minutes ago, the nurse notes a large amount of red vaginal bleeding. What would be the initial priority nursing action?
-
Solution
Provide fundal massage
Fundal massage also called uterine massage is done to reduce bleeding and cramping of the uterus after childbirth. This would be the priority nursing action since it directly addresses the problem.
Options A and C are appropriate nursing actions, but do nothing to stop the immediate bleeding.
Option B: Breastfeeding the baby will stimulate the release of oxytocin, which will cause uterine contraction, but it will be slower to do so than the fundal massage.
A nurse in the labor room is monitoring a client with dysfunctional labor for signs of maternal or fetal compromise. Which of the following assessment findings would alert the nurse to a compromise?
-
Solution
Meconium in the amniotic fluid
Signs of maternal or fetal compromise include passage of meconium, decreased movement felt by the mother, nonreassuring fetal heart rate, and fetal metabolic acidosis.
Options A and C: Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.
Option D: Maternal fatigue can occur with prolonged labor, but do not indicate maternal or fetal compromise.
The lower limit of viability for infants in terms of age of gestation is:
-
Solution
21-24 weeks
Viability means the capability of the fetus to live/survive outside of the uterine environment. With the present technological and medical advances, 21 weeks AOG is considered as the minimum fetal age for viability.
Which of the following conditions will lead to a small-for-gestational-age fetus due to less blood supply to the fetus?
-
Solution
Maternal cardiac condition
In general, when the heart is compromised such as in maternal cardiac condition, the condition can lead to less blood supply to the uterus consequently to the placenta which provides the fetus with the essential nutrients and oxygen. Thus if the blood supply is less, the baby will suffer from chronic hypoxia leading to a small-for-gestational-age condition.