Obstetric Nurse Obstetric Emergencies Questions and Answers — Questions and Answers
Question 1: A nurse is assisting with a delivery complicated by shoulder dystocia. After the provider has attempted gentle traction without success, which nursing intervention should be prioritized?
- Applying fundal pressure.
- Assisting the client into the McRoberts maneuver position. (Correct answer)
- Preparing for an immediate cesarean section.
- Encouraging the client to push with an open glottis.
Correct answer: Assisting the client into the McRoberts maneuver position.
The McRoberts maneuver, which involves hyperflexing the mother's legs onto her abdomen, is a primary, evidence-based intervention for shoulder dystocia. [8, 14] This maneuver flattens the sacral promontory and rotates the pubic symphysis, which can free the impacted anterior shoulder. [6] Applying fundal pressure is contraindicated as it can worsen the impaction of the shoulder and increase the risk of fetal injury. [11, 15] While preparing for other interventions is important, McRoberts is a key initial step. Pushing is ineffective until the shoulder is dislodged.
Question 2: A client with a history of a previous classical cesarean section is in active labor. Which of the following clinical findings would be most indicative of a uterine rupture?
- A gradual increase in the intensity of contractions.
- The presenting part moving down the birth canal.
- A fetal heart rate tracing showing early decelerations.
- A sudden, sharp abdominal pain followed by a cessation of contractions. (Correct answer)
Correct answer: A sudden, sharp abdominal pain followed by a cessation of contractions.
A classic sign of uterine rupture is the sudden onset of intense, tearing abdominal pain, often followed by a complete stop in uterine contractions as the uterus loses its integrity. [12, 39] Other signs include a non-reassuring fetal heart rate pattern (like bradycardia or prolonged decelerations), loss of fetal station (the presenting part moves up, not down), and signs of maternal shock. [27, 39] Early decelerations are generally benign, and a gradual increase in contraction intensity is expected in normal labor.
Question 3: A multiparous client has a precipitous vaginal delivery. Moments after birth, she becomes acutely dyspneic, hypotensive, and cyanotic. She then experiences a seizure and develops disseminated intravascular coagulation (DIC). These findings are most characteristic of which obstetric emergency?
- Pulmonary embolism.
- Amniotic fluid embolism. (Correct answer)
- Eclamptic seizure.
- Postpartum hemorrhage.
Correct answer: Amniotic fluid embolism.
Amniotic fluid embolism (AFE), or anaphylactoid syndrome of pregnancy, is a rare but catastrophic complication. Its classic presentation is the sudden onset of cardiopulmonary collapse (hypotension, dyspnea), often followed by neurologic symptoms (seizures) and coagulopathy (DIC). [4, 10, 25] While a pulmonary embolism causes respiratory distress and eclampsia involves seizures, the rapid combination of all these symptoms, especially the profound coagulopathy, points strongly to AFE. [18, 29]
Question 4: A client at 8 weeks gestation presents to the emergency department with a 2-day history of spotting and crampy lower abdominal pain. She now reports a sudden, severe, unilateral lower quadrant pain that radiates to her shoulder. Which condition should the nurse be most concerned about?
- Ruptured ectopic pregnancy. (Correct answer)
- Miscarriage.
- Appendicitis.
- Ovarian torsion.
Correct answer: Ruptured ectopic pregnancy.
The development of sudden, severe, unilateral pain along with referred shoulder pain (Kehr's sign) is a hallmark sign of a ruptured ectopic pregnancy with intraperitoneal hemorrhage. [7, 21] The bleeding irritates the diaphragm and phrenic nerve, causing pain to be referred to the shoulder area. [21] While the other conditions cause abdominal pain, the referred shoulder pain in a client with signs of early pregnancy is highly suggestive of a ruptured ectopic pregnancy. [23, 41]
Question 5: A nurse is caring for a client receiving a continuous intravenous infusion of magnesium sulfate for preeclampsia with severe features. Which of the following assessment findings is the earliest sign of magnesium sulfate toxicity?
- Respiratory rate of 8 breaths per minute.
- Loss of deep tendon reflexes (DTRs). (Correct answer)
- Urine output of 15 mL/hr.
- Sudden drop in blood pressure.
Correct answer: Loss of deep tendon reflexes (DTRs).
Magnesium sulfate is a central nervous system depressant. The loss or diminution of patellar deep tendon reflexes is typically the first and most sensitive sign that the magnesium level is becoming toxic. [9, 13, 32] Respiratory depression (rate <12/min), oliguria (<30 mL/hr), and hypotension are later, more severe signs of toxicity that occur at higher serum concentrations. [1, 36, 38]
Question 6: Immediately following the delivery of the placenta, the nurse observes a large, red, rounded mass protruding from the introitus. The client reports severe abdominal pain and her blood pressure drops to 80/40 mmHg. What is the nurse's priority action?
- Administer a bolus of oxytocin.
- Vigorously massage the protruding mass.
- Cover the mass with a warm, moist sterile towel.
- Anticipate the need for a tocolytic agent and notify the provider. (Correct answer)
Correct answer: Anticipate the need for a tocolytic agent and notify the provider.
This clinical picture describes an acute uterine inversion, a life-threatening emergency. The immediate priority is to facilitate uterine replacement by the provider. [2, 5, 34] This requires uterine relaxation, which is achieved with a tocolytic agent (e.g., terbutaline, nitroglycerin). [3, 26] Administering an uterotonic like oxytocin would cause the uterus to contract further, making replacement impossible. [3, 5] Massaging the inverted uterus is inappropriate. While covering the mass is a supportive measure, the absolute priority is alerting the provider and preparing for the intervention that will allow replacement, which is uterine relaxation.
Obstetric Nurse Obstetric Emergencies Questions and Answers
A nurse is assisting with a delivery complicated by shoulder dystocia.
After the provider has attempted gentle traction without success, which nursing intervention should be prioritized?