Exam 16: Nursing Care During Obstetric Procedures

The labor nurse is providing care for a patient admitted for induction of labor at 38 weeks' gestation. The patient's Bishop score is 5, and an infusion of oxytocin (Pitocin) is initiated with orders that read as follows: mix 30 units of Pitocin in 500 mL of NS, increase the rate of infusion by 2 mL/hr every 15 to 60 minutes until a pattern of three contractions in 10 minutes is established. What is the priority nursing action for this patient?

Which condition is a contraindication for an amniotomy?

Which breech presentation should the nurse recognize as being favorable for an external cephalic version?

When a laboring client receiving 12 mU of pitocin for induction develops a contraction pattern of every 2 minutes lasting 80 seconds and recurring late decelerations, the nurse should immediately:

The nurse monitors the client in labor for signs and symptoms of water intoxication. Which finding indicates that this may be occurring?

The greatest risk to the newborn after an elective cesarean birth is:

Which event indicates a complication of an external version?

A client is being sent into the labor and birth unit for a serial induction of labor. The Bishop's score is 7. What would the nurse anticipate as the sequence of treatment planned for this client?

In which of these situations should the nurse anticipate the use of forceps or vacuum extraction?

A client is scheduled for an external cephalic version (ECV). Which should the nurse prepare to implement? (Select all that apply.)

Which is an appropriate response to a client's comment that she is worried about having a cesarean birth?

A client asks the nurse, "What can I do to avoid an episiotomy during birth?" Which responses should the nurse give? (Select all that apply).

Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

In which client situation could an amniotomy be safely performed?

The priority nursing intervention following an amniotomy is to:

Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?

After a forceps-assisted birth, the client is observed to have continuous bright red lochia but a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?

Select the situation that describes the safest administration of oxytocin induction and cervical ripening agents.

The nurse is positioning the Foley catheter prior to a cesarean birth. Which position should the nurse use to place the catheter drainage tubing and catheter bag?

For which client should the oxytocin (Pitocin) infusion be discontinued immediately?