Maternity Case: Amelia Sung

1. Which of the following pregnancy-related conditions increase the risk for shoulder dystocia? Correct answer- Uncontrolled maternal gestational diabetes Rationale: Uncontrolled gestational diabetes leads to fetal macrosomia, fat pads at the fetal neck, and increased maternal weight gain, all factors that increase the incidence of shoulder dystocia. Preeclampsia and IUGR both result in smaller infants and thus do not increase the risk of shoulder dystocia. Hyperemesis, while it can continue throughout the pregnancy, is generally a problem of the first trimester and not related to the delivery. 2. The nurse documents the following events: crowning at 0749, fetal head emerged at 0800, McRobert's maneuver performed at 0802, suprapubic pressure applied at 0806, and fetal body delivered at 0808. What is the significance of documenting these events? Correct answer- Provides an indicator of the potential for fetal compromise Rationale: Documenting this sequence of events provides an indicator of the potential for fetal compromise related to decreased oxygenation. The time of birth is when the entire body is born. The focus is on the well-being of the mother and fetus/baby, not the team's response. The Apgar score is assigned using the standard criteria. 3. The nurse has assessed that the patient in labor is at risk of shoulder dystocia. After delivery of the fetal head, the nurse states in a clear, loud voice, "Fetal heart rate 90 beats per minute with minimal variability." Why is it important for the nurse to communicate this information? Correct answer- To inform the provider about the fetal status Rationale: A call-out is a clear and concise statement of data or an event that everyone on the health care team needs to know to care for the patient effectively. Changes in the FHR are not routinely announced in the delivery room, but in this situation the call-out by the nurse is important to give data to the provider so the provider can evaluate the fetal status and determine the next course of action. The patient is focused on pushing out the fetus, so the information is not for her benefit. The nurse's interpretation of routine fetal activity is documented in the patient's chart, not verbally. 4. What is the first action by the nurse to assist with the delivery of the fetal shoulders and body when there is shoulder dystocia? Correct answer- Flex the mother's thighs toward her abdomen Rationale: Flexing the legs toward the abdomen allows the pelvis to open to its maximum dimension. This position is used prior to application of suprapubic pressure. Fundal pressure will not dislodge the fetal shoulders from under the bone. Placing the mother's legs in stirrups enhances visualization but will not facilitate delivery of the fetus. 5. Which of the following are common fetal or neonatal injuries seen after shoulder dystocia? (Select all that apply) Correct answer- Asphyxia, Erb's palsy, Fractured clavicle Rationale: Erb's palsy occurs due to stretching of the brachial plexus. The clavicle or humerus may be fractured during the manipulation to free the shoulders. Asphyxia is a risk because the head is delivered in advance of the body and there is pressure on the cord and placenta, which alters fetal oxygenation. Shoulder dystocia does not cause injuries to the lower body or lower extremities, such as fractured femur or talipes equinovarus. 6. What is a positive turtle sign? Correct answer- The fetal head emerges and then retracts tightly against the perineal floor. Rationale: A positive turtle sign is when the head delivers and then is retracted back and rests firmly against the perineum. 7. When a shoulder dystocia emergency is anticipated, what additional actions should be implemented by the nurse? (Select all that apply) Correct answer- Explain to the patient and family what may happen, Put a step stool at the bedside, Have extra staff available if needed Rationale: The stool is used so the provider applying suprapubic pressure can stand directly over the patient. Extra staff is needed to implement the maneuvers used to deliver the fetal shoulders. Communicating to the patient and family about what might happen in the delivery room will help to prepare them and to decrease their anxiety. Removing the family from the delivery room is not a therapeutic response and will further increase their anxiety. A consent for a cesarean delivery is not appropriate at this time. 8. A patient is admitted to the labor and delivery unit at 40 weeks gestation. Which of the following pieces of information collected during the patient interview would be most significant in alerting the nurse to the potential for shoulder dystocia? (Select all that apply) Correct answer- Estimated fetal weight 8 lb, 13 oz (4,000 g) or more, Maternal height 5 ft, 3 in (160 cm), Maternal weight gain greater than 50 lb (23 kg) Rationale: Excessive maternal weight gain, short stature of the mother, and high estimated fetal weight are risk factors for shoulder dystocia. Ethnicity is a demographic factor not associated with this condition. Previous delivery is evidence that she is able to deliver an infant of that size, and an active phase of labor lasting 4 hours is not a significant finding. 9. Shoulder dystocia is a complication of labor related to which of these factors? Correct answer- Prolonged second stage of labor Rationale: Shoulder dystocia occurs when the anterior fetal shoulder gets stuck behind the mother's pubic bone. A prolonged second stage of labor is a factor related to the presence of shoulder dystocia. Uterine contractions are usually of adequate strength. The volume of amniotic fluid and the length of the active phase of labor are not risk factors for shoulder dystocia. 10. VSIM scenario (91%) Correct answer- *Wash your hands Identify the patient *Calm and support the patient *Examine the patient's chest as part of head to toe assessment *Examine the patient's legs as part of head to toe assessment *Check for edema *Assess patient's temperature as part of vital signs *Prepare the bassinet *Prepare the delivery table *Make sure step stool is available *Give patient 100% O2 via non-rebreathing mask *Turn oxygen on at 10L *Encourage pushing *Listen to lungs *Check deep tendon reflexes *Assess patient's IV as part of assessment *Provide patient education *Calm and support patient **IF FETAL MONITOR SHOWS NON-REASSURING FETAL HR start bolus of LR at 500 mL over 15 min *Instruct patient to push *Encourage pushing *Calm and support patient and family *Encourage pushing *Encourage pushing *Encourage pushing *Listen to patient's heart as part of assessment *Listen to patient's lungs as part of assessment *Encourage pushing *Calm and support patient and family *Provide patient education *Call the charge nurse *Call the NICU *Assist patient into McRoberts position *Encourage pushing **WHEN PROVIDER ORDERS TO APPLY SUPRAPUBIC PRESSURE, apply suprapubic pressure *Encourage pushing *Hand the baby to the charge nurse 11. When assuming responsibility for Ms. Sung's care, the nurse reviews the patient's history and admissions assessment. Based on this information, which anticipatory tasks should the nurse implement before delivery? (Select all that apply) Correct answer- Empty the patient's bladder, Educate the patient and family, Alert key personnel, Put a step stool next to the birthing bed Rationale: Anticipation, preparation, and having key personnel informed are all key to prevention of morbidity and mortality during a shoulder dystocia emergency. Tocolytic medications and magnesium sulfate infusions are not used in the management of shoulder dystocia. 12. The fetus's head emerges and a positive turtle sign is observed. Whom would the nurse call into the delivery room at this time? (Select all that apply) Correct answer- Neonatal intensive care unit (NICU) personnel, Charge nurse Rationale: Additional personnel are needed in the room, so the charge nurse needs to know. NICU medical personnel are needed for a potential neonatal resuscitation. The other persons are not involved in the events taking place in the delivery room. 13. Which of the following would be the best initial communication for the nurse to make when calling the NICU? Correct answer- This is the nurse in birthing room 2. Ms. Sung is pushing and the head is delivered. Turtle sign is positive. Estimated fetal weight is 4,000 grams. The fetal heart rate is currently 90 bpm with decreased variability. McRobert's maneuver is being done. We need a NICU team for possible neonatal asphyxia or fetal injury. Rationale: This response includes all components of a situation-background-assessment-recommendation (SBAR) report. It gives the NICU nurse the patient's history, the fetus's current status, and details about what is being done. This allows the NICU nurse to anticipate the situation and what type of equipment to bring to the delivery room. The other options lack important data needed by the NICU team to anticipate the infant's needs. 14. When the provider applied suprapubic pressure during Ms. Sung's delivery, what was the goal? Correct answer- Push the fetus's anterior shoulder downward and under the pubic bone Rationale: Suprapubic pressure is intended to dislodge the shoulder that is being obstructed by the pubic bone. Fundal pressure augments the strength of the uterine contraction and is contraindicated in this situation. If the head is delivered, it has passed through the vagina. 15. Which of the following pieces of information about the birth should be documented when shoulder dystocia has occurred? Correct answer- Time the head emerges, time maneuvers are implemented, and time the shoulders/body emerge Rationale: The timing and sequence of events between the birth of the head and the birth of the body are critical and need to be accurately documented. The provider will also need to know how much time has elapsed after each maneuver is performed. 16. The provider directs the nurse to begin McRobert's maneuver. The nurse knows to take which of the following actions? Correct answer- Hyperflex the patient's legs to her abdomen Rationale: In McRobert's maneuver, the patient's legs are hyperflexed toward the abdomen to allow the fetal shoulder to pass under the pubic bone. The other positions described may move the shoulder more tightly toward the pubic bone. 17. After the fetal head emerges, the nurse notes that the fetal heart rate is 90 beats per minute (bpm) with minimal variability. Which action should the nurse implement first? Correct answer- Administer oxygen Rationale: There is an order to administer oxygen based on fetal heart rate parameters. 18. After shoulder dystocia is diagnosed, which maneuvers are implemented to facilitate the delivery of the fetal body? (Select all that apply) Correct answer- Suprapubic pressure, Woods' screw maneuver, McRobert's maneuver Rationale: McRobert's maneuver, suprapubic pressure, and Woods' screw maneuver, in this order, are all used to dislodge the fetus with shoulder dystocia. A fern procedure identifies the presence of amniotic fluid in the vagina. Fundal pressure aids the expulsive forces of labor and is contraindicated in situations with shoulder dystocia. 19. After experiencing shoulder dystocia, the patient is at increased risk for which of the following complications? (Select all that apply) Correct answer- Vaginal laceration, Postpartum hemorrhage, Bladder trauma Rationale: Due to the manipulation needed to deliver the baby's body, there is increased risk of postpartum hemorrhage, vaginal lacerations, and bladder trauma. Shoulder dystocia does not increase the risk of paralytic ileus or deep vein thrombosis. 20. When was the diagnosis of shoulder dystocia made in Ms. Sung's case? Correct answer- When the newborn's head delivered without the delivery of the neck and body Rationale: Shoulder dystocia occurs when the fetus's shoulders become lodged behind the mother's pubic bone. As a result the fetal head delivers, but the neck and body are unable to emerge from the birth canal.