Obstetric Nurse Labor and Birth Process Flashcards

A patient at 41 weeks gestation is undergoing cervical ripening with a Foley balloon catheter. Which finding indicates the catheter has served its purpose and should be removed?

Answer: The balloon spontaneously expels or the cervix reaches 3–4 cm dilation

The Foley balloon catheter for cervical ripening is designed to fall out when the cervix dilates to approximately 3–4 cm, indicating adequate cervical change.

During the third stage of labor, which clinical sign indicates placental separation has occurred?

Answer: The fundus rises in the abdomen, the cord lengthens, and a gush of blood is seen

Signs of placental separation include the fundus rising and becoming globular, cord lengthening, and a sudden gush of blood.

A laboring patient at 39 weeks with GBS-positive status has been in labor for 2 hours since rupture of membranes. She has a penicillin allergy with a prior anaphylactic reaction. What antibiotic should the nurse anticipate administering?

Answer: Vancomycin IV

For GBS-positive patients with a high-risk penicillin allergy (anaphylaxis history) and GBS resistant to clindamycin, vancomycin is the recommended alternative agent.

A primipara in active labor at 5 cm requests an epidural. After placement, her blood pressure drops from 118/72 to 88/54 mmHg. The FIRST nursing action should be:

Answer: Place her in left lateral position and increase IV fluid infusion rate

Epidural-induced hypotension is managed first by lateral positioning (to relieve aortocaval compression) and a rapid IV fluid bolus.

What is the MOST reliable method for confirming rupture of membranes when a patient reports a slow fluid leak?

Answer: Observing pooling of fluid in the posterior vaginal fornix and performing nitrazine and ferning tests

Confirming SROM requires visualizing pooling of amniotic fluid, a positive nitrazine test (pH >6.5 turns blue), and a ferning pattern on a dried vaginal slide.

During active labor, a nurse notes the FHR baseline is 175 bpm for 15 minutes with minimal variability. Maternal temperature is 38.4°C. What condition should the nurse suspect?

Answer: Intrauterine infection (chorioamnionitis) causing fetal tachycardia

Maternal fever combined with fetal tachycardia and decreased variability is a classic presentation of chorioamnionitis, which requires antibiotic therapy and often expedited delivery.

Which action by the nurse BEST demonstrates application of evidence-based practice during pushing in the second stage of labor?

Answer: Encouraging open-glottis (laboring down) pushing, following the patient's own urge to push

Evidence-based practice supports open-glottis, spontaneous (physiologic) pushing triggered by the patient's urge, which reduces maternal exhaustion and improves fetal oxygenation compared to Valsalva pushing.