Chapter 023 PS
Chapter 023 PS
Chapter 023 PS
CD PATIENT SCENARIO
Molly Deska is a 24-year-old, G3P1, 37-week pregnant woman admitted to the maternity
CHIEF CONCERN:
Molly was alerted at her last prenatal visit that her fetus was in a posterior position so
labor might be long. Contractions began 8 hours ago; pattern has never become regular.
having such back pain with contractions she asks to have something for pain relief.
FAMILY PROFILE:
Client not employed as she volunteers days at center for children who are cognitively
challenged where her older son attends preschool and volunteers as a waitress in
are "tight." Couple lives in a furnished apartment above a tavern that her paternal grand-
parents own. Marriage is "shaky" due to strain of finances, family disagreements, and
Maternal aunt has child with Down syndrome, Molly's father died of liver failure from
alcoholism at 45. Husband's family has "many" people with peptic ulcers.
GYNECOLOGICAL HISTORY:
Menarche at 14 years; cycle duration: 28 days; length of menstrual flow: 7 days. Treated
for exposure to syphilis at 18 years. Was using vaginal foam as contraceptive before
OBSTETRICAL HISTORY:
Spontaneous abortion 4 years ago. Boy, 8 pounds 4 ounces, vaginal delivery, born 3 years
ago with Down syndrome. Present pregnancy was planned and welcomed. Attended late
for prenatal care (6th month) because of finances. No amniocentesis or CVS for
DAY HISTORY:
Nutrition: 24-hour nutrition recall reveals diet high in carbohydrate and low in protein.
Sleep: Sleeps 6 hours at night. Bar downstairs is “too noisy” until after 3 a.m. to sleep
before that.
Recreation: Does not participate in an active exercise program. Walks “lots” every
PHYSICAL EXAMINATION
General Appearance: Distressed and exhausted appearing, obese, young adult pregnant
HEENT: negative.
Chest: Heart rate: 76 beats per minute; physiologic splitting marked. Lungs: clear to
Abdomen: Fundal height: 38 cm. Fetus palpated to be in left occiput posterior position
and large by Leopold's movements. Head fixed in pelvis. FHR: 150 beats per minute.
Pelvic Examination: Diagonal conjugate measured at 12 cm. Pubic arch wide; ischial
diameter: 12 cm; coccyx movable. Cervical dilation: 4 cm; effacement: 20%. Station: 0.
Bishop Score: 9
Extremities: Unremarkable.
hypotonic contractions.
2. If contractions are hypertonic, their resting tone will be above average. A usual
resting tone is
a. 5 mm Hg.
b. 15 mm Hg.
c. 25 mm Hg.
d. 45 mm Hg.
Answer: d. It is important that uterine arteries fill between contractions to supply enough
b. 1 hour.
c. 3 hours.
d. 5 hours.
Answer: b. The second stage of labor is short related to the first stage. As long as descent
5. Formation of a pathologic contraction ring is a danger sign of labor. To assess for this,
you would
abdomen.
birth, prolonged labor, oxytocin induction, and an abnormal presentation are all risks for
uterine rupture.
7. Which of the following would be a sign that uterine rupture has occurred?
Answer: b. If a uterus tears (ruptures), the woman first feels sharp pain. Bleeding will be
8. Placenta accreta can cause a complication of labor. When this occurs, the
Answer: c. A placenta accreta is one unusually deeply attached so it can not be readily
condition below in her history would make you question whether this technique is
Answer: a. Molly’s pregnancy is only 37 weeks. An immature fetal skull is softer than
a. abdominal contour.
b. bladder emptying.
d. rectal bleeding.
Answer: c. Assessing the fetal heart rate would assure the fetal cord was not compressed
by the maneuver.
11. Molly has been given pitocin, which has begun to strengthen uterine contractions.
a. Estrogen
b. Prostaglandin
c. Dopamine inhibitor
d. Oxytocic
contractions.
12. The degree of Molly’s cervix ripening is rated as 9 on a Bishop Scale. Based on this,
you would
c. alert her M.D. that her cervix is still too immature for oxytocin.
d. infuse the oxytocin at half the prescribed rate until the scale is 12.
Answer: b. A score of 8 to 10 indicates a cervix is “ripe” or soft and ready for dilation.
13. Suppose Molly has prostaglandin E2 applied to her cervix to increase cervical
ripening before labor. Side effects of this drug for which you would assess include
c. severe hypertension.
d. rectal bleeding.
Answer: c. Hypertension, diarrhea, vomiting, and fever are all common side effects of
become too frequent or too intense. Always use a pump to decrease the possibility of
oxytocin overdose.
15. A side effect of oxytocin administration is water intoxication. A signal that this is
Answer: c. Water intoxication means fluid is pooling in interstitial spaces. This increased
tension leads to headache and vomiting and mental confusion. Urine flow would be
decreased.
16. Molly’s baby is large, which means the baby is at risk for shoulder dystocia. Which
finding in the newborn would be most important to assess for following shoulder
dystocia in labor?
a. Blue tinged toes and fingers
d. Uncoordinated respirations
Answer: d. As the newborn’s head is bent to the side to help deliver the wide shoulders,
movements.
a. Decreased hearing
b. Signs of dehydration
c. Corneal irritation
d. Sinus congestion
Answer: b. The baby's face is extremely edematous following birth, so much so that
experiences sudden pressure changes to the head, possibly resulting in tearing of cranial
vessels.
19. Amniotic fluid embolism is a potential complication of labor. Which statement below
Answer: c. Amniotic embolism means amniotic fluid has entered the maternal
20. Suppose Molly’s baby is a forceps birth. Although rarely used today, the advantage of
Answer: b. When forceps are applied, pressure is exerted on the forceps, not the fetal
head.