Unit 3 Maternity Exam - Greater Lowell Technical School

Explanation:

Correct Answer: (C) 11.

In Lamaze slow-paced breathing, the recommended breathing rate during contractions is approximately half the woman's normal baseline respiratory rate. With a baseline respiratory rate of 22 breaths per minute, half of that is 11 breaths per minute. This rate provides controlled, calming respirations that help manage pain during contractions without going so slow as to cause hypoventilation or respiratory compromise.

Why Other Options are Incorrect:

A. A rate of 20 breaths per minute is essentially the same as the baseline rate and does not represent the intentionally slower, controlled breathing pattern that is the goal of Lamaze slow-paced breathing technique during contractions.

B. A rate of 9 breaths per minute is below the recommended threshold of half the baseline rate and could lead to hypoventilation, reduced oxygen delivery to the mother and fetus, and increased carbon dioxide retention, which is unsafe.

D. A rate of 15 breaths per minute is approximately two-thirds of the baseline rate rather than half, which is not consistent with the Lamaze guideline of using approximately half the baseline respiratory rate for slow-paced breathing.

Explanation:

Correct Answer: (B) Reposition the patient.

Sudden variable decelerations following membrane rupture are highly suggestive of umbilical cord compression, which can occur from cord prolapse or cord entrapment after the cushioning amniotic fluid is released. The immediate priority nursing action is to reposition the patient, typically to the left lateral position or knee-chest position, to relieve pressure on the cord and restore fetal oxygenation before notifying the healthcare provider.

Why Other Options are Incorrect:

A. Administering oxytocin would increase uterine contractions and worsen cord compression, further reducing fetal oxygenation. Oxytocin is absolutely contraindicated when variable decelerations indicate cord compromise.

C. Performing an amniotic infusion requires a physician order and an intrauterine pressure catheter and cannot be initiated by the nurse independently as a priority action before provider notification. It may be ordered subsequently to relieve cord compression.

D. Increasing IV fluids is a supportive measure that may improve uteroplacental perfusion but does not directly address the cord compression causing the variable decelerations. Repositioning is the more immediate and targeted intervention for relieving cord compression.

Explanation:

Correct Answer: (B) Above the ischial spines.

Station refers to the relationship of the fetal presenting part to the ischial spines of the maternal pelvis, which serve as the zero reference point. A station of -1 means the presenting part is 1 centimeter above the ischial spines, indicating the fetus has not yet fully descended into the pelvis. Negative numbers indicate the presenting part is above the ischial spines, while positive numbers indicate it is below.

Why Other Options are Incorrect:

A. Visible at the perineum describes a station of +4 or +5, which is crowning and indicates imminent delivery. This is the complete opposite of a -1 station where the presenting part is still above the ischial spines.

C. Below the ischial spines describes positive stations such as +1, +2, or +3, indicating the fetus has descended past the ischial spines. This is incorrect for a -1 station, which places the presenting part above the spines.

D. Engaged in the mother's pelvis describes a station of 0, meaning the widest diameter of the presenting part has passed through the pelvic inlet and is level with the ischial spines. At -1 station, engagement has not yet occurred as the presenting part remains above the spines.

Explanation:

Correct Answer: (A) Help her breathe into her cupped hands.

When a laboring woman hyperventilates, she blows off excessive carbon dioxide, leading to respiratory alkalosis, tingling, and dizziness. Having her breathe into her cupped hands allows her to rebreathe the exhaled carbon dioxide, restoring CO2 levels and correcting the respiratory alkalosis. This is the immediate, simple, and effective first-line intervention that the nurse can implement without a physician order.

Why Other Options are Incorrect:

B. Notifying the doctor is not the immediate priority for hyperventilation, which is a common and manageable occurrence in labor that the nurse can independently address with breathing techniques before escalating to the physician.

C. Placing her flat on her back is contraindicated in labor as the supine position compresses the inferior vena cava by the gravid uterus, reducing venous return and cardiac output, which can cause supine hypotensive syndrome and fetal distress.

D. Initiating oxygen at 2 liters via a mask would worsen the situation by providing more oxygen without addressing the excess CO2 loss that is causing the hyperventilation and respiratory alkalosis. Oxygen therapy is not the treatment for hyperventilation-induced respiratory alkalosis.

Explanation:

Correct Answer: (C) Notify healthcare provider for a temperature above 38.0°C (100.4°F).

With premature rupture of membranes (PROM) at 34 weeks, the primary risk is chorioamnionitis, which is infection of the amniotic membranes and fluid. A temperature above 38.0°C (100.4°F) is the earliest and most reliable sign of developing infection and must be reported immediately to the healthcare provider so that prompt evaluation and treatment can be initiated to protect both the mother and fetus.

Why Other Options are Incorrect:

A. Resting in a side-lying Trendelenburg position with hips elevated is indicated when cord prolapse has occurred to relieve pressure on the cord. It is not a standard home discharge instruction for PROM without confirmed cord prolapse, and maintaining this position continuously at home is impractical and unnecessary.

B. Reporting an increase in fetal activity is not the appropriate teaching point. Decreased fetal movement, not increased movement, is a warning sign requiring immediate reporting as it may indicate fetal compromise or infection-related distress.

D. Massaging the breasts stimulates oxytocin release and promotes uterine contractions, which would be contraindicated in a woman with PROM at 34 weeks where the goal is to delay labor and allow further fetal maturation.

Explanation:

Correct Answer: (C) Discontinue oxytocin.

Late decelerations indicate uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen during uterine contractions. When the patient is receiving oxytocin, the immediate priority is to discontinue the infusion to reduce uterine stimulation, decrease contraction frequency and intensity, and allow more time for placental blood flow and fetal oxygenation to recover between contractions. Continuing oxytocin in the presence of late decelerations would worsen fetal hypoxia.

Why Other Options are Incorrect:

A. Performing Leopold's Maneuver assesses fetal position and presentation and is not an appropriate response to an acute fetal heart rate abnormality indicating fetal distress. This assessment does not address the immediate cause of the late decelerations.

B. Administering tocolytics such as terbutaline may be used in certain situations of uterine tachysystole but is not the first-line response when late decelerations are present in a patient receiving oxytocin. Discontinuing the oxytocin is the simpler and more immediate priority intervention.

D. Increasing IV fluids is a component of the full management of late decelerations to improve uteroplacental perfusion, but it should follow the immediate priority of discontinuing the oxytocin that is directly contributing to the problem by over-stimulating uterine contractions.

Explanation:

Correct Answer: (A) Hyperventilation.

Blurred vision, numbness, and tingling of the hands and mouth are classic symptoms of hyperventilation-induced respiratory alkalosis. When a laboring woman breathes too rapidly and deeply, she blows off excessive carbon dioxide, causing a drop in PaCO2 that leads to cerebral vasoconstriction producing blurred vision, and peripheral neuromuscular changes causing the characteristic circumoral and hand tingling and numbness. This is a common occurrence during intense labor contractions and is managed by having the patient breathe into cupped hands to rebreathe CO2.

Why Other Options are Incorrect:

B. Hypertension in labor would present with severe headache, visual disturbances such as scotomata, epigastric pain, and edema consistent with preeclampsia. While visual changes can occur, the combination with hand and mouth tingling specifically points to hyperventilation rather than hypertension.

C. Anxiety can contribute to hyperventilation and may be the underlying trigger, but anxiety itself does not directly cause the specific neurological symptoms of numbness and tingling in the hands and mouth. These symptoms are the direct result of the CO2 changes from hyperventilation.

D. Hypoxia would present with cyanosis, decreased oxygen saturation, altered consciousness, and tachycardia. The specific pattern of circumoral tingling and hand numbness is not characteristic of hypoxia but is the hallmark presentation of hypocapnia from hyperventilation.

Explanation:

Correct Answer: (A) Labor has progressed to the transition phase.

Transition is the final and most intense part of the first stage of labor, occurring between approximately 8-10 cm dilation. However, at 7 cm with contractions every 3 minutes, the patient is entering the transition phase. This phase is characterized by the most intense contractions, shortest rest intervals, and the greatest psychological and emotional distress, including irritability, loss of coping ability, cursing, crying, and feelings of being overwhelmed. This behavior is a normal and expected manifestation of transition labor.

Why Other Options are Incorrect:

B. Contractions increasing from mild to moderate intensity occurs earlier in labor during the active phase. At 7 cm with contractions 3 minutes apart, contractions are already severe in intensity, making this explanation insufficient to account for the dramatic behavioral change observed.

C. Attributing the behavioral change to inadequate preparation is judgmental and incorrect. Even women who are very well prepared for childbirth commonly exhibit irritability, emotional distress, and loss of coping during transition labor due to the extreme physiological intensity of this phase.

D. While pain management should always be considered and offered, attributing the behavioral change solely to a need for different analgesia ignores the normal physiological explanation of transition labor and does not represent the most accurate clinical assessment of the situation.

Explanation:

Correct Answer: (B) In knee chest position with thighs at right angles to bed.

When a prolapsed umbilical cord is detected, the priority is to immediately relieve pressure on the cord to prevent fetal hypoxia. The knee-chest position uses gravity to shift the presenting part away from the cord, effectively relieving compression. The nurse must also manually hold the presenting part off the cord with a gloved hand while awaiting emergency cesarean delivery.

Why Other Options are Incorrect:

A. Supine with legs elevated does not adequately relieve pressure on a prolapsed cord and the supine position can worsen the situation by allowing the presenting part to continue compressing the cord against the pelvis.

C. Left lateral side-lying with a pillow between the legs is the standard positioning for uteroplacental insufficiency and general labor comfort, but it does not provide sufficient gravity-assisted relief of cord compression in the emergency of cord prolapse.

D. Positioning on her back with her head lower than the rest of her body is a modified Trendelenburg position which can provide some relief but is less effective than the knee-chest position in using gravity to shift the presenting part away from the prolapsed cord.