Which of the following patients does the nurse recognize as a good candidate for a trial of labor after cesarean (TOLAC) and possible VBAC (vaginal birth after cesarean)?
A G2P1001 at 41 weeks gestation with a fetus in a transverse presentation. She has had one previous delivery, a spontaneous vaginal delivery at 42 weeks gestation.
A 33-year-old G5P2204 at 37 weeks and two days gestation. Her previous deliveries were scheduled low-transverse cesarean sections.
A 42-year-old G2P1001 at 38 weeks gestation carrying a fetus with an estimated fetal weight of 6 lbs 8 oz. Her first cesarean section was scheduled due to a breech position of the fetus.
A 29-year-old G3P1011 at 39 weeks gestation. She has had one previous delivery, an emergent cesarean section with a classical vertical uterine incision.
The Correct Answer is C
Choice A rationale
This patient is not a good candidate due to the transverse fetal presentation. A fetus in a transverse lie cannot be delivered vaginally because the largest diameter of the fetus is positioned across the maternal pelvis. This presentation poses a significant risk of complications, including uterine rupture, necessitating a cesarean delivery.
Choice B rationale
This patient is not a good candidate because a history of multiple cesarean sections increases the risk of uterine rupture during a trial of labor. While a previous low-transverse uterine incision is generally considered a good candidate for TOLAC, the increased number of prior cesareans significantly raises the risk profile.
Choice C rationale
This patient is an ideal candidate for TOLAC. The previous cesarean section was for a non-recurring indication (breech presentation), not for a cephalo-pelvic disproportion. The estimated fetal weight is within a normal range, and the patient has a single previous low-transverse uterine incision, which is the safest type for a trial of labor.
Choice D rationale
This patient is not a good candidate for TOLAC because a previous classical vertical uterine incision has a significantly higher risk of uterine rupture during labor. This type of incision involves the contractile part of the uterus, and the scar is more likely to dehisce under the stress of uterine contractions, making TOLAC contraindicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Guided imagery is a cognitive-behavioral technique that uses mental focus on a peaceful scene or image to distract from pain. While it can be an effective pain management strategy for some women in labor, it is not specific to the physiological cause of back labor. Back labor pain is caused by the occiput of the fetus pressing against the maternal sacrum, which requires a physical, rather than a psychological, intervention to be most effective.
Choice B rationale
Progressive relaxation is a technique that involves tensing and relaxing different muscle groups throughout the body to relieve tension and promote comfort. Like guided imagery, it is a general pain management technique that can be useful for reducing overall labor discomfort. However, it does not directly address the specific cause of back labor, which is the physical pressure from the fetal head on the sacrum.
Choice C rationale
Slow, deep breathing is a common and effective technique for managing labor pain by promoting relaxation, increasing oxygenation, and distracting the patient. It helps the woman focus and cope with contractions. While beneficial for managing labor pain, it is not a targeted intervention for the intense, localized pressure and pain associated with back labor, which responds better to direct physical pressure.
Choice D rationale
Back labor pain is caused by the occiput of the fetus pressing against the maternal sacrum. Counterpressure is a physical intervention that involves applying firm, steady pressure with the heel of the hand or a fist against the sacral area during contractions. This direct pressure helps to displace the fetal head and counteract the pain, making it a highly effective and specific relief measure for back labor.
Correct Answer is D
Explanation
Choice A rationale
The term "flexed attitude" describes the posture of the fetus, not its position relative to the pelvic inlet. The engagement of the presenting part is a measure of station, which indicates how low the fetus has descended into the pelvis. A fetus can be flexed without being engaged.
Choice B rationale
A transverse lie describes the fetal axis being perpendicular to the maternal spine. The attitude refers to the relationship of the fetal parts to one another, such as the position of the head relative to the chest. A fetus can have a flexed attitude in a longitudinal or transverse lie.
Choice C rationale
Breech presentation is when the fetal buttocks or feet present first into the pelvis. Attitude describes the posture of the fetal limbs and head. While a fetus in breech presentation can have a flexed attitude, the terms describe different aspects of the fetus's position and posture.
Choice D rationale
The flexed attitude is the normal and most common fetal posture during labor. This position is characterized by the fetal chin resting on its chest, with the arms and legs crossed over the abdomen. This posture allows the smallest diameter of the fetal head to present to the pelvic inlet, facilitating descent.
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