The nurse and student are discussing clients who are laboring on the unit.
Which clients would the nurse encourage to attempt a vaginal birth after having a cesarean section? Select all that apply.
A client who had rupture of membranes 26 hours ago.
A client with a current separation of symphysis pubis.
A client who had a cesarean section because of placenta previa.
A client who had a cesarean section because of a breech presentation.
A client who was positive for Group B streptococcal infection.
A client who has a gynecoid shaped pelvis.
Correct Answer : C,D,F
Choice A rationale
Prolonged rupture of membranes (PROM), especially beyond 18-24 hours, significantly increases the risk of intrauterine infection (chorioamnionitis) for both mother and fetus. Infection is a contraindication or at least a major caution for a trial of labor after cesarean (TOLAC) as it adds physiological stress and could necessitate an urgent repeat cesarean, complicating recovery. The normal range for time from rupture to delivery is generally under 24 hours.
Choice B rationale
A current separation of the symphysis pubis (diastasis symphysis pubis), often causing significant pelvic girdle pain and instability, presents a mechanical risk during labor and vaginal delivery. The excessive strain and pressure of pushing could exacerbate the separation, leading to severe maternal morbidity, chronic pain, and long-term musculoskeletal dysfunction, thus generally contraindicating a TOLAC.
Choice C rationale
Placenta previa, which occurs when the placenta covers the cervix, necessitating the previous cesarean, is an obstetric indication not expected to recur in subsequent pregnancies with the same certainty as issues like contracted pelvis or certain uterine incision types. With no recurrent previa and an otherwise favorable presentation, the client is a good candidate for a trial of labor after cesarean (TOLAC) because the prior indication was temporary.
Choice D rationale
A breech presentation, which describes the fetus positioned with the buttocks or feet first, was the fetal indication for the previous cesarean section. Assuming the current fetus is in a cephalic (head-down) presentation, this non-recurrent fetal issue makes the client a suitable candidate for a trial of labor after cesarean (TOLAC), as the uterus itself and the maternal pelvis are likely accommodating.
Choice E rationale
Group B streptococcal (GBS) colonization is a common bacterial finding in the lower genital tract, typically managed with prophylactic intravenous antibiotics (e.g., Penicillin) during labor. GBS positivity is a standard infectious risk factor managed with antibiotics and does not contraindicate a trial of labor after cesarean (TOLAC) itself, as it is routinely treated to prevent neonatal sepsis.
Choice F rationale
The gynecoid pelvis is considered the most favorable pelvic shape for vaginal delivery due to its rounded inlet, adequate mid-pelvis, and wide subpubic arch, which allows for optimal fetal head engagement and rotation. This favorable anatomy increases the likelihood of a successful trial of labor after cesarean (TOLAC) and is a strong positive predictive factor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12"]
Explanation
Step 1 is to convert the oxytocin concentration from units to milliunits (mU):. 20 units× 1000 mU/unit = 20000 mU.
Step 2 is to determine the concentration in mU/mL:. 20000 mU÷ 1000 mL = 20 mU/mL.
Step 3 is to calculate the infusion rate in mL/min:. 4 mU/min÷ (20 mU/mL) = 0.2 mL/min.
Step 4 is to convert the infusion rate from mL/min to mL/hr:. 0.2 mL/min× 60 min/hr = 12 mL/hr. The final calculated answer is 12 mL/hr.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Postpartum hemorrhage (PPH) is a significant risk for this client due to several factors including a macrosomic neonate (birth weight >4000 grams), which causes overdistention of the uterus. Uterine overdistention stretches the muscle fibers, impairing the uterus's ability to contract effectively (uterine atony) after birth, which is the leading cause of PPH (normal blood loss range: ≤ 500 mL for vaginal birth).
Choice B rationale
A rapid labor (4 hours) and the birth of a macrosomic neonate (4200 grams) increase the risk of vaginal lacerations and tears to the soft tissues of the birth canal. The rapid passage of a large fetal head/shoulder diameter can cause uncontrolled and forceful tearing, often extending into the perineal musculature, leading to potential complications and excessive blood loss.
Choice C rationale
Uterine inversion, the collapse of the fundus into the endometrial cavity, is a rare but severe complication. While associated with factors like aggressive cord traction or fundal pressure, this client's history of macrosomia and rapid labor primarily increases the risk for uterine atony and lacerations, making inversion a much less likely, though possible, complication.
Choice D rationale
Postpartum hypertension (PHTN) is generally related to a history of pre-eclampsia or chronic hypertension. This client's presentation of macrosomia and rapid labor primarily increases the risk for mechanical/anatomical complications like uterine atony and lacerations rather than a primary vasospastic or systemic vascular disorder such as PHTN.
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