306 Ricci Chapter 13: Labor and Birth Process
The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care?
a woman may spend time thinking about what is happening to her Women need a support person with them during all stages of labor.
A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is:
"It is rounded in shape and allows ample room for the neonate to fit through the passageway." The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid pelvis inlet allows the fetus room to pass through the dimensions of the bony passageway.
During which time is the nurse correct to document the end of the third stage of labor?
at the time of placental delivery The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.
Assessment of a pregnant woman in labor reveals that the fetal attitude is normal. The nurse interprets this as indicating which information? Select all that apply.
chin is on the chest legs are flexed at the knees Fetal attitude refers to the posturing (flexion or extension) of the joints and the relationship of fetal parts to one another. The most common fetal attitude when labor begins is with all joints flexed—the fetal back is rounded, the chin is on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The fetus is in a longitudinal lie.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?
occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.
The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor?
reduce the rate of cesarean births among low risk women Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?
shoulder The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?
the client reports back pain, and the cervix is dilating and effacing True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.
The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic?
cephalohematoma Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. Instructions for care include simple observation of the area. The cephalohematoma will subside in a couple of weeks and may take a couple of months to completely go away. There is no brain damage associated with a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?
"She is in active labor; she is progressing at this point and we will keep you posted." At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.
The five "Ps" of labor are:
passageway, passenger, position, powers, psych. The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
the cervix is softening The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
the client's cervix is fully dilated The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?
the frequency of the contractions is every 5 minutes Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply.
begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity True contractions begin irregularly but become regular and predictable; are felt first in the lower back and sweep around to the abdomen in a wave; continue no matter what the woman's level of activity; increase in duration, frequency, and intensity; and achieve cervical dilatation. False (Braxton Hicks) contractions begin and remain irregular; are felt first abdominally and remain confined to the abdomen and groin; often disappear with ambulation or sleep; do not increase in duration, frequency, or intensity; and do not achieve cervical dilatation.
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:
1 cm above the ischial spines Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and referred to as a minus or plus, depending on its location above or below the ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spine, it is recorded as plus stations. Therefore this fetus is 1 cm above the ischial spines.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?
4+ As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document?
completion of the third stage of labor The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The fourth stage begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1 to 4 hours after birth). Within this fourth stage, the attachment process begins with the mother inspecting the newborn and desiring to cuddle and breastfeed the newborn.
A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:
occurring about every 5 minutes The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are *commonly felt in the lower back*, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, *if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant*.
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?
push with contractions and rest between them Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.
A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement?
"I feel pressure in my vaginal when I have a contraction" True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation (dilatation) would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
During a prepared childbirth class, the nursing is discussing the differences between true and false labor. Which responses by a client indicate an understanding of false labor? Select all that apply.
"Maintaining hydration by drinking water will lessen false labor pains." "The intensity of contractions is inconsistent in false labor." False labor is a phenomena that occurs in the later weeks of pregnancy. During false labor, the woman may experience contractions. These contractions may vary in intensity. They do not become regular nor do they increase in intensity. Activity such as walking can increase contraction strength and frequency during true labor, but walking does not increase the manifestations of false labor. Remaining hydrated is important. Dehydration may result in uterine irritability and false labor pains. False labor pains are felt in the abdomen; in contrast, true labor contractions begin in the back and radiate to the front of the abdomen. Pelvic pressure increases during true labor.
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?
"She is in active labor; she is progressing at this point and we will keep you posted" At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.
A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?
"You are still 2 cm dilated, but the cervix is thinning out nicely" Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilatation but not effacement. Therefore, just saying, "no further dilatation" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.
A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate?
"You need the cervix to thin so it can stretch more easily" The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?
Braxton Hicks contractions are usually decreased in intensity by walking Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
Lightening bloody show backache The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilation (dilatation). Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?
ROA The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.
In which situation would the nurse anticipate client admission to the labor and delivery unit? Select all that apply.
The client is experiencing regular contractions every 5 minutes. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation). The client reports a burst of energy and completion of the nursery. Documented pelvic change from last health care provider visit. The client reports a gush of fluid from the perineal region. Anticipated signs that labor will begin are regular contractions occurring every 5 minutes, having a thin cervix with progressive dilation (dilatation), a burst of energy, pelvic changes as the cervix thins and dilates, and a gush of fluid (which is amniotic fluid). Fetal kicks throughout the day are a reassuring sign that the fetus is moving in the uterus.
A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate?
administer the medication piggybacked into a primary IV line using a pump Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It is not given orally, via IM injection, or through a central venous access device.
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
as k the woman to describe why she believes that she is in labor The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not she is in labor. The client may be in false labor, and more information should be obtained before she is brought to the hospital.
A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting?
buttocks The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?
cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?
complete cervical dilation (dilatation) of 10 cm and ends with the delivery of he neonate The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?
crowning Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?
decrease in circulation and perfusion to the fetus When monitoring fetal responses in a client experiencing labor, the nurse should monitor for a decrease in circulation and perfusion to the fetus secondary to uterine contractions. The nurse should monitor for an increase, not a decrease, in arterial carbon dioxide pressure. The nurse should also monitor for a decrease, not an increase, in fetal breathing movements throughout labor. The nurse should monitor for a decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen.
Which cardinal movement of delivery is the nurse correct to document by station?
descent Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:
descent, flexion, internal rotation, extension, external rotation, expulsion The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?
effacement The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.
In which manner is the fetal status best assessed during the active and transition stages of labor?
fetal heart rate at the peak of contraction Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best indicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
fetal lie Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?
fetal position When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor?
first, active Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor, which is characterized by cervical dilation (dilatation) of 4 to 7 cm. Regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and at -1 station. The second stage of labor begins when the cervix is 10 cm dilated. The first latent phase is characterized by the onset of regular contractions and cervical dilation (dilatation) of 0 to 4 cm. The third stage of labor is from birth of the infant to completed delivery of the placenta.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?
head elevated, grasping knees, breathing out An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.
increase in heart rate increase in blood pressure increase in respiratory rate When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in systolic blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?
increased white blood cell count The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.
A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?
is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis.
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?
latent phase The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage 2 she may remain positive, but the work of labor is very intense.
A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?
long axis of fetus is perpendicular to that of client If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.
The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?
molding The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply.
oxytocin, progesterone, prostaglandins There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?
pain from the dilation (dilatation) or stretching of the cervix In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.
When educating a group of nursing students about the different types of pelves, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type?
platypelloid A platypelloid pelvis is a flat pelvis with a wider transverse diameter than anterior-posterior diameter, ischial spines are wide apart, and the sacrum is short. In a gynecoid pelvis, the inlet is oval, the pubic arch is wide, it has dull ischial spines, and the sacrum has no anterior or posterior inclinations. In an android pelvis, the inlet is heart shaped, the ischial spines are prominent, and the sacrum is straight. In an anthropoid pelvis, the anterior-posterior diameter is longer than the transverse diameter, the ischial spine is somewhat prominent, and the sacrum is inclined posteriorly.
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?
push with contractions and rest between them Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?
relaxin As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.
A nurse is conducting an in-service program for a group of nurses working in the prenatal clinic. When discussing the theories about the onset of labor, the nurse points out which factor as a possible cause? Select all that apply.
release of oxytocin by the pituitary prostaglandin production in the myometrium The possible causes for the onset of labor include an increase in the fetal cortisol levels, release of oxytocin by the posterior pituitary, and the production of prostaglandins. Progesterone withdrawal, and not an increase, initiates labor. There is a rise in the estrogen levels at 34 to 35 weeks' of pregnancy. Estrogen stimulates prostaglandin production and also promotes the release of oxytocin.
A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:
the buttocks are presented first with both legs extended up towards the face In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.
Which client outcome during active and transitional labor is best?
the client will practice breathing techniques during contractions The nurse identifies a priority during the active and transitional stage of labor as working with the contractions to give birth. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level is under 7 in the active and transitional phases. Walking in the hall and tolerating liquids also depends on the client.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?
the fetus is in the true pelvis and engaged When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor?
these contractions help in softening and ripening of the cervix Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?
third Stage three begins with the birth of the baby and ends with delivery of the placenta.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?
transition phase The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation (dilatation) of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.
The above nurse's note was documented in the client's record by the labor room nurse. In which position was the client born?
with the occiput facing the right anterior quadrant of the pelvis A fetus in the vertex presentation has the occiput as the reference point. If the occiput is facing the anterior quadrant of the pelvis, the nurse is correct to record the position as ROA. Proper notation does not include a rear or right facing position. The vertex presentation is associated with the fetal occiput, not brow.
