A patient in labor has been diagnosed with uterine dystocia and is experiencing late decelerations in fetal heart rate. The medical team decides to initiate IV oxytocin to augment labor. As a nurse, what is your priority action while administering oxytocin in this scenario?

B) Continuously monitor fetal heart rate and uterine contraction patterns closely.

A) Increase the oxytocin infusion rate every 15 minutes until contractions are regular.

B) Continuously monitor fetal heart rate and uterine contraction patterns closely.

C) Encourage the patient to ambulate to promote fetal descent.

D) Administer a tocolytic agent to manage uterine hyperstimulation.

A patient in labor with a history of a previous cesarean section presents with irregular and weak uterine contractions, decreased fetal movement, and late decelerations on the fetal heart rate monitor. An ultrasound reveals the fetus in an occiput posterior position and decreased amniotic fluid levels. Which nursing intervention should take priority in this scenario?

A) Administer oxygen to the mother and reposition her to the left lateral position.

B) Prepare the patient for an immediate cesarean section without further monitoring.

C) Increase the dose of oxytocin to strengthen uterine contractions aggressively.

D) Provide the mother with comfort measures and encourage walking to promote fetal descent.

A 30-year-old patient is in labor and receiving intravenous oxytocin for labor augmentation. The fetal heart rate shows recurrent late decelerations and minimal baseline variability. The patient has a blood pressure of 145/95 mmHg, elevated liver enzymes, low platelet count, and +2 proteinuria. What is the most appropriate nursing action given these findings?

C) Reposition the patient to a left lateral position and apply oxygen.

A) Increase the oxytocin infusion rate to enhance labor progression.

B) Administer a fluid bolus to the patient to improve fetal perfusion.

C) Reposition the patient to a left lateral position and apply oxygen.

D) Prepare for an emergency cesarean section as per the healthcare provider's order.

A patient receiving intravenous oxytocin for labor augmentation presents with persistent fetal heart rate late decelerations and minimal variability. Laboratory findings suggest preeclampsia with elevated liver enzymes, low platelet count, and proteinuria. Considering the ongoing fetal distress and maternal condition, what is the most appropriate nursing action?

C) Initiate preparations for an emergency cesarean section.

A) Increase the rate of oxytocin infusion to enhance labor progress.

B) Administer antihypertensive medication to manage the elevated blood pressure.

C) Initiate preparations for an emergency cesarean section.

D) Continue to monitor the patient closely and reassess in 30 minutes.

A pregnant patient in labor presents with irregular contractions, elevated blood pressure, headache, and proteinuria. The fetal heart rate shows late decelerations and minimal variability. Which nursing intervention is most critical to address first in this scenario?

C) Prepare the patient for an emergency cesarean section

A) Administer a bolus of IV fluids

B) Position the patient in a left lateral position

C) Prepare the patient for an emergency cesarean section

D) Administer antihypertensive medication immediately

A patient in labor presents with severe preeclampsia and signs of uterine exhaustion. Which nursing intervention is most appropriate to prioritize at this time?

C) Prepare the patient for an emergency cesarean section

A) Continue oxytocin infusion to maintain labor progress

B) Administer antihypertensive medication as per protocol

C) Prepare the patient for an emergency cesarean section

D) Increase the patient's fluid intake to improve uterine perfusion

A nurse is preparing to provide care for a patient with severe preeclampsia who is undergoing an emergency cesarean section. Which of the following interventions should the nurse prioritize to stabilize the patient before surgery?

A) Administer magnesium sulfate to prevent seizures.

B) Start an infusion of intravenous fluids to manage hypotension.

C) Provide oxygen therapy at 2 L/min via nasal cannula to improve oxygenation.

D) Offer reassurance to the patient to help reduce her anxiety.

A patient with severe preeclampsia is being prepared for an emergency cesarean section. Her blood pressure is 162/105 mmHg, she exhibits brisk reflexes with clonus, and her lab results show elevated creatinine and transaminases. Which of the following nursing interventions is most critical prior to the administration of regional anesthesia?

A) Administer magnesium sulfate to reduce the risk of seizures.

B) Increase IV fluid rate to manage potential hypotension.

C) Position the patient in a left lateral position to improve placental perfusion.

D) Provide oxygen therapy to maintain adequate fetal oxygenation.

A nurse is caring for a patient with severe preeclampsia who is receiving magnesium sulfate infusion for seizure prophylaxis. Which clinical sign indicates that the nurse should immediately notify the healthcare provider due to potential magnesium toxicity?

B) Blood pressure of 160/100 mmHg

A patient undergoing an emergency cesarean section for severe preeclampsia is receiving a magnesium sulfate infusion for seizure prophylaxis. Which of the following assessments is most critical for the nurse to perform to monitor for magnesium toxicity?

B) Assess the patient's deep tendon reflexes

A) Monitor for visual disturbances

B) Assess the patient's deep tendon reflexes

C) Check blood pressure regularly

D) Evaluate fetal heart rate patterns

intrapartum - Nursing Case Study

Pathophysiology

• Primary mechanism: Uterine contractions - Coordinated contractions of the uterine muscle (myometrium) are essential for cervical dilation and the descent of the fetus through the birth canal. These contractions are primarily driven by the hormone oxytocin, which increases uterine muscle sensitivity and frequency of contractions.

• Secondary mechanism: Fetal positioning and passage - The fetus must be optimally positioned (usually occiput anterior) to navigate the maternal pelvis. Malpositions or malpresentations can lead to obstructed labor, impacting the effectiveness of contractions and progress of labor.

• Key complication: Uterine dystocia - Ineffective uterine contractions can lead to prolonged or stalled labor, increasing the risk of maternal and fetal complications such as infection, hypoxia, and the need for interventions like cesarean delivery.

Patient Profile

Demographics:

28-year-old female, teacher

History:

• Key past medical history: Gestational diabetes, previous cesarean section

• Current medications: Prenatal vitamins, insulin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Labor pains with excessive discomfort

• Key symptoms: Severe abdominal pain, decreased fetal movement, vaginal bleeding

• Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, temperature 37.8°C, respiratory rate 22 breaths per minute

Section 1

As the labor progresses, the medical team conducts an initial assessment to evaluate the patient's status and identify any further complications. Upon examination, the uterine contractions are noted to be irregular and weak, consistent with uterine dystocia. The cervical dilation is assessed at 3 cm, indicating slow progression despite the onset of labor pains several hours ago. The fetal heart rate monitoring reveals a concerning pattern of late decelerations, suggesting potential fetal distress. The decreased fetal movement reported by the patient is corroborated by the non-reassuring heart rate pattern. Given the patient's previous cesarean section and current symptoms, the risk of uterine rupture is considered.

To further investigate the situation, an ultrasound is performed, revealing the fetus in an occiput posterior position, which can contribute to labor dystocia and increased maternal discomfort. Additionally, the ultrasound shows decreased amniotic fluid levels, raising concerns about oligohydramnios, which may compromise fetal well-being. The combination of fetal malposition, uterine dystocia, and signs of fetal distress heightens the urgency for intervention.

Based on these findings, the healthcare team decides to initiate intravenous (IV) oxytocin to augment labor contractions, with careful monitoring of the fetal response. The decision is made in the context of balancing the need to enhance labor progression while minimizing the risk of exacerbating fetal distress or uterine rupture. The patient's blood pressure remains elevated, and a lab draw is ordered to assess for preeclampsia, given her current symptoms and history of gestational diabetes. The clinical team remains vigilant, ready to escalate to a repeat cesarean section if there is no improvement or if the fetal distress persists.

Section 2

As the infusion of intravenous oxytocin progresses, the healthcare team closely monitors the patient's response and the fetal heart rate pattern. Initially, there is a slight increase in the frequency and strength of the uterine contractions, suggesting a positive response to the augmentation. However, the fetal heart rate continues to show recurrent late decelerations with a baseline variability that remains minimal, indicating persistent fetal distress. The patient's blood pressure continues to be elevated, with a reading of 145/95 mmHg, prompting further investigation into her hypertensive status.

Laboratory results return, revealing mildly elevated liver enzymes and a low platelet count, which are concerning for the development of preeclampsia. The team also notes a proteinuria level of +2, reinforcing this suspicion. Given these findings and the patient's pre-existing condition of gestational diabetes, there is an increased risk for maternal and fetal complications. The decision-making process becomes more complex, balancing the need to progress labor while considering the potential need for an urgent cesarean section to prevent further maternal and fetal compromise.

In light of the persistent fetal distress, the obstetric team conducts a thorough reassessment. The patient's cervix is now dilated to 4 cm, showing minimal progression despite the oxytocin therapy. The fetal position remains occiput posterior, contributing to the labor dystocia. With the ongoing signs of fetal distress and the new evidence of potential preeclampsia, the team discusses the risks and benefits with the patient and her family, preparing for the possibility of an expedited delivery to ensure the safety and well-being of both the mother and the baby.

Section 3

As the team prepares for potential expedited delivery, the patient's status begins to change. Despite the continued oxytocin infusion, the contractions become irregular and less effective, with intervals becoming longer and the intensity decreasing. This alteration in contraction pattern suggests uterine exhaustion, a concern given the prolonged labor and the minimal cervical dilation progress. Concurrently, the patient's blood pressure rises further to 155/100 mmHg, exacerbating the hypertensive concerns and increasing the risk of complications such as eclampsia or placental abruption. The nursing team swiftly reassesses her pain and discomfort level, noting increased agitation and complaints of a persistent headache, which further indicate potential preeclampsia progression.

In response to these developments, the obstetric team decides to halt the oxytocin infusion to mitigate the risk of further uterine stress and potential uterine rupture. Continuous fetal monitoring reveals that the fetal heart rate pattern remains concerning, with recurrent late decelerations and minimal variability persisting despite modifying maternal positions and administering supplemental oxygen. The severity of the situation escalates with the additional finding of increased proteinuria at +3, further corroborating the diagnosis of severe preeclampsia. This combination of persistent fetal distress, the patient's hypertensive crisis, and the unyielding labor dystocia prompts the team to prioritize an emergency cesarean section.

The decision is communicated clearly to the patient and her family, emphasizing the critical need to ensure both maternal and fetal safety. The medical team swiftly coordinates the logistics of the surgical intervention, ensuring that all necessary preparations, such as anesthesia and neonatal care, are ready to proceed. This decisive action underscores the importance of timely clinical reasoning and intervention in managing intrapartum complications, as the focus shifts to stabilizing the patient and delivering the baby safely.

Section 4

As the team prepares for the emergency cesarean section, the initial assessment in the operating room reveals additional concerns. The patient's blood pressure continues to climb, now reading 162/105 mmHg, highlighting the urgency of the situation. She remains visibly agitated, and her headache persists despite prior administration of analgesics, indicating that her condition may be worsening. Her reflexes are brisk, with a positive clonus noted upon examination, which further supports the suspicion of progressing severe preeclampsia. These findings necessitate immediate and focused interventions to stabilize her before surgery.

Amid these preparations, new diagnostic results return from the lab, showing a rising creatinine level of 1.4 mg/dL, indicating renal involvement, which is consistent with the severe preeclampsia diagnosis. Her liver function tests reveal elevated transaminases, with AST and ALT levels now at 85 and 92 U/L, respectively, suggesting potential hepatic strain. These results reinforce the critical need for swift surgical intervention to prevent further maternal complications and potential multi-organ dysfunction.

The anesthesiology team, aware of the patient's hypertensive crisis and potential coagulation issues, opts for careful administration of regional anesthesia, closely monitoring her hemodynamic status throughout. Meanwhile, the neonatal team stands ready to address any immediate needs of the newborn, anticipating potential impacts from the prolonged labor and maternal complications. This coordinated, multidisciplinary approach exemplifies the necessity for comprehensive clinical reasoning and interprofessional collaboration, ensuring the best possible outcomes for both mother and child in this high-stakes scenario.

Section 5

As the team continues to prepare for the emergency cesarean section, a sudden change in the patient's status raises additional concerns. The patient's blood pressure skyrockets to 175/110 mmHg, despite attempts to manage her hypertension with intravenous labetalol. Her agitation increases, and she begins to experience visual disturbances, reporting flashes of light and blurred vision, classic signs of worsening preeclampsia. The nurse quickly reassesses her neurological status, noting that her headache has intensified and her clonus is now more pronounced. These symptoms suggest an increased risk of eclampsia, necessitating immediate intervention to prevent seizures.

In response, the obstetrician orders a magnesium sulfate infusion to be started as a seizure prophylaxis. The nursing team works swiftly to initiate the infusion, carefully monitoring the patient for any signs of magnesium toxicity, such as a decrease in respiratory rate or loss of deep tendon reflexes. Concurrently, the anesthesiology team decides to proceed with a general anesthetic rather than regional anesthesia due to the patient's unstable condition and the potential for rapid decompensation. This decision highlights the delicate balance required in managing the patient's critical status while also preparing for the delivery of the baby.

As the magnesium sulfate begins to take effect, the patient's agitation slightly decreases, and her reflexes stabilize, suggesting some level of stabilization. However, the team remains vigilant, aware that her renal function and liver enzymes continue to be compromised. With the patient now prepped for surgery, the focus shifts to ensuring a safe and efficient delivery, while the neonatal team remains on high alert, ready to provide immediate support to the newborn who may be affected by the maternal complications. This scenario underscores the importance of dynamic clinical reasoning and continuous assessment, as the team navigates the complexities inherent in severe preeclampsia and its potential impact on both mother and child.