Ch 5 Intrapartum

The prenatal record is a

The prenatal record is a summary of the woman's history from the time she entered prenatal care until the record was sent to the labor room (usually at 36 weeks' gestation or later). Virtually all of the physical and psychosocial information relating to this woman is pertinent to the care by the nurse. For example, if a woman has gained very little weight during her pregnancy, the baby may be small-for-gestational age. The nurse may also have to change his or her care in relation to the woman's ethnicity

1. A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1. 1, 2, 3, and 5 are correct. 1. Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. 2. The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. 3. The client's age should also be noted before the physical assessment is begun. 4. The type of insurance the woman has is not relevant to the nurse. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth—should also be noted before a physical assessment is begun.

10. During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA − 1 station. 2. LSP − 1 station. 3. LMP +1 station. 4. LSA +1 station.

10. 1. The LOA position refers to a fetus whose occiput (O) is facing toward the mother's left anterior (LA) and a presenting part at − 1 station is 1 cm above the ischial spines. 2. The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and buttocks at − 1 station are 1 cm above the ischial spines. 3. The LMP position refers to a fetus whose face (M or mentum) is facing toward the mother's LP and a presenting part at +1 is 1 cm below the ischial spines. 4. The LSA position refers to a fetus whose buttocks (S) are facing toward the mother's LA and a presenting part at +1 station is 1 cm below the ischial spines.

11. The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

11. 1. A fetus in the mentum anterior position is unlikely to elicit severe back pain in the mother. 2. A fetus in the sacral posterior position is unlikely to elicit severe back pain in the mother. 3. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain. 4. A fetus in the scapula anterior position is unlikely to elicit severe back pain in the mother.

12. When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

12. 1. The left upper quadrant would be the appropriate place to place a fetoscope to hear the fetal heartbeat if the baby were in the LSA position, not the LOA position. 2. The right upper quadrant would be appropriate if the baby were in the RSA position. 3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question. 4. The right lower quadrant would be appropriate if the baby were in the ROA position.

13. On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

13. 1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines. 2. The fetal head is well past engagement. Engagement is defined as 0 station. 3. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away. 4. External rotation does not occur until after delivery of the fetal head.

14. One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

14. 1. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. 2. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. 3. Although this client is fully dilated, the cervix is not fully effaced and the baby has not descended far enough. 4. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

15. The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

15. 3, 4, and 5 are correct. 1. Hypnotic suggestion is usually not included in childbirth education based on the Lamaze method. 2. Rhythmic chanting is usually not included in childbirth education based on the Lamaze method. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effl eurage, is also an integral part of Lamaze childbirth education.

16. The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear-tensionpain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

16. 1. Childbirth educators are not concerned with the possible verbalizations that laboring women might make. 2. Breathing exercises can be quite tiring. Simply being in labor is tiring. The goal of childbirth education, however, is not related to minimizing the energy demands of labor. 3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle. 4. Although childbirth educators discuss maternal-newborn bonding, it is not a priority goal of childbirth education classes.

17. The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing.

17. 1. The alternate pant-blow technique is used during stage 1 of labor. 2. Rhythmic, shallow breaths are used during stage 1 of labor. 3. Open glottal pushing is used during stage 2 of labor. 4. Slow chest breathing is used during stage 1.

18. A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal examinations and blood tests. 2. Focusing the discussion on baby care rather than on labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

18. 1. It is important to include all relevant information in the childbirth class. 2. Baby care should be included, but it is also important to include information about labor and delivery. 3. Using visual aids can help to foster learning in teens as well as adults. 4. Having the classes conveniently located in the school setting often enhances teens' attendance.

19. A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fi ngers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

19. 1. Although this client is light-headed, her problem is unlikely related to her blood pressure. 2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. 3. It is unnecessary for this client to be moved to her side. 4. The baby is not in jeopardy at this time.

2. A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

2. 1. Leopold maneuvers, although performed on a woman in labor, assess for fetal position, not the progress of labor. 2. Fundal contractility will assess for uterine contractions, but this is not the most valuable information. 3. Assessment of the fetal heart is critically important in relation to fetal well-being, but it will not determine the progress of labor. 4. A vaginal examination will provide the nurse with the best information about the status of labor. Each of the assessments listed is performed on a woman who enters the labor suite for assessment. However, the only assessment that will determine whether or not a woman is in true labor is a vaginal examination. Only when there is cervical change—dilation and/or effacement—is it determined that a woman is in true labor.

20. A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

20. 1. The pant-blow breathing technique is usually used during the transition phase of labor. 2. Rapid, deep breathing is rarely used in labor. 3. Grunting and pushing, characteristic of open glottal pushing, is the method that women instinctively use during the second stage of labor. It is also the safest method of pushing. 4. Most women find slow chest breathing effective during the latent phase.

21. A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing fi rst-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing.

21. 1. It is inappropriate to encourage her to have an epidural at this time. 2. It is inappropriate to encourage her to have an IV analgesic at this time. 3. A change of position might help but will probably not be completely effective. 4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time.

22. In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

22. 1. The lithotomy position is not physiologically supportive of labor and birth. 2. Effleurage is a light massage that can soothe the mother during labor. 3. Practicing Kegel exercises can help to build up the muscles of the perineum but will not help the woman to work with her labor. 4. Pushing is not performed until the second stage of labor.

23. A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

23. 1. The woman should not push until the next contraction. She should be allowed to sleep at this time. 2. The woman's privacy should be maintained while she is resting. 3. The woman is in no apparent distress. Vital sign assessment is not indicated. 4. The woman is in no apparent distress. Oxygen is not indicated.

24. A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform fi rst? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

24. 1. This client has probably moved into the second stage of labor. Providing a bedpan is not the first action. 2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor. 3. It is too early to notify the physician. 4. It is too early to advise the mother to push.

25. The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the healthcare practitioner. 4. Place the client on her left side and apply oxygen by face mask.

25. 1. This is the correct response. A fetal heart rate of 152 is normal. 2. This woman is in early labor. The fetal heart does not need to be assessed every 5 minutes. 3. The rate is normal. There is no need to report the rate to the healthcare practitioner. 4. The rate is normal. There is no need to institute emergency measures.

26. The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Only during the peak of contractions. 4. For 1 minute immediately after contractions.

26. 1. The frequency of intermittent auscultation is determined by which stage of labor the woman is in. 2. The frequency of intermittent auscultation is determined by which stage of labor the woman is in. 3. The fetal heart rate should be assessed before, during and after contractions. 4. Intermittent auscultation should be performed for 1 full minute after contractions end.

27. While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

27. 1. The tracing is showing a normal fetal heart tracing. No intervention is needed. 2. There is no need to administer oxygen at this time. The tracing is normal. 3. If the client is comfortable, there is no need to change her position. 4. There is no need to speed up the intravenous at this time.

28. While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

28. 1. The relationship between the decelerations and the contractions will determine the type of deceleration pattern. 2. The maternal blood pressure is not related to the scenario in the question. 3. Although some fetuses are at higher risk for fetal distress, the nurse must first determine which type of deceleration is present. 4. If the nurse is able to identify that a deceleration is present, the electrode placement is adequate.

29. A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

29. 1. Breathing will help with contraction pain but is not as effective when a client is experiencing back labor. 2. It is inappropriate automatically to encourage mothers to have anesthesia or analgesia in labor. There are other methods of providing pain relief. 3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head. 4. Hydrotherapy is very soothing but will not provide direct relief.

3. A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

3. 1. There is no indication that this woman has had poor preparation for childbirth. 2. The woman is showing expected signs of the active phase of labor. 3. There is no indication that this woman is showing signs of hypoxia and/or hypercapnia. 4. The alpha-fetoprotein assessment is a test to screen for Down syndrome and neural tube defects in the fetus. It is done during pregnancy.

30. An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

30. 1. The maternal blood pressure is not the priority assessment after an amniotomy. 2. The maternal pulse is not the priority assessment after an amniotomy. 3. It is essential to assess the fetal heart rate immediately after an amniotomy. 4. Fetal fibronectin is assessed during pregnancy. It is not assessed once a woman enters labor.

31. A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

31. 1. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed in the LUQ. 2. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed LLQ. 3. Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. 4. The monitor electrode should have been placed in the RLQ if the nurse had assessed a vertex presentation.

32. Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and − 3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

32. 1. This client is fully dilated and effaced, but the baby is not yet engaged. Until the baby descends and stimulates rectal pressure, it is inappropriate for the client to begin to push. 2. Fundal pressure is inappropriate. 3. Many women push in the squatting position, but it is too early to push at this time. 4. Monitoring for rectal pressure is appropriate at this time.

33. A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous infusion rate.

33. 1 and 2 are correct. 1. An appropriate action by the doula is giving the woman a back massage. 2. An appropriate action by the doula is to assist the laboring woman with her breathing. 3. The nurse, not the doula, should assess the fetal heart. 4. The nurse, not the doula, should assess the blood pressure. 5. The nurse, not the doula, should regulate the IV.

34. The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

34. 1. Women may contract without being in true labor. 2. Once the cervix begins to dilate, a client is in true labor. 3. Membranes can rupture before true labor begins. 4. Engagement can occur before true labor begins.

35. The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fl uid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

35. 1, 2, and 4 are correct. 1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 3. Expelling the mucous plug is not sufficient reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconiumstained fluid. The client needs to be assessed. 5. The latent phase of labor can last up to a full day. In addition, Braxton Hicks contractions can last for quite a while. Even though a woman may feel cramping for 4 hours or more, she may not be in true labor.

36. A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

36. 1. This client may be in the latent phase of labor or may be experiencing false labor contractions. Either way, unless she is having other symptoms, there is no need to be seen by a healthcare practitioner. 2. This client is having some bloody show with the expulsion of the mucous plug, but pink streaks are normal and can be seen hours to a few days before true labor begins. 3. This client may be in the latent phase of labor, but there is no need to go to the hospital with "cramping." 4. This client is exhibiting clear signs of true labor. Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen.

37. A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

37. 1. The client may have a urinary tract infection with blood in the urine. First, however, the nurse should acknowledge the client's concerns. 2. The nurse is using reflection to acknowledge the client's concerns. 3. Although the woman's statement is consistent with the expulsion of the mucous plug, this response ignores the fact that the client is frightened by what she has seen. 4. The nurse will want to clarify that the woman isn't actually bleeding, but the question should follow an acknowledgment of the woman's concerns.

38. A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions hurt more than they did before." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."

38. 1. The frequency of labor contractions decreases. It does not increase. 2. Labor contractions increase in intensity. They do not become milder. 3. This response indicates that the labor contractions are increasing in intensity. 4. This client has slept through the "tightening" and there is no increase in intensity. It is unlikely that she is in true labor.

39. A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

39. 1. The frequency and duration of this contraction pattern is every 2 minutes lasting 60 seconds. 2. The frequency and duration of this contraction pattern is every 4 minutes lasting 120 seconds. 3. The frequency and duration of this contraction pattern is every 3 minutes lasting 120 seconds. 4. The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds.

4. A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

4. 1, 2, and 4 are correct. 1. The nurse should assess the fetal heart before reporting the client's status to the healthcare provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 3. A complete urinalysis would likely be ordered by the primary healthcare practitioner once the client has been offi cially admitted, but the test would not be performed during the initial assessment process. 4. The nurse should assess the woman's vital signs before reporting her status. 5. A biophysical profi le is performed only if ordered by a healthcare practitioner. The fetal heart, contraction pattern, and maternal vitals all should be assessed to provide the healthcare practitioner with a picture of the health status of the mother and fetus. In some institutions, the nurse may also do a vaginal examination to assess for cervical change.

40. A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

40. 1. A fetus in a sacral presentation is in a vertical lie. 2. A fetus in an occipital presentation is in a vertical lie. 3. A fetus in a mentum presentation is in a vertical lie. 4 A fetus in a scapular presentation is in a horizontal lie.

41. A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.

41. 1, 5, 3, 4, 2. The correct order of the movements listed is: 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion.

42. The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this fi nding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

42. 1. Engagement is equal to 0 station. This fetus is well past 0 station. 2. A baby who is floating is in negative station. 3. When the presenting part is at the ischial spines, the baby is engaged or at 0 station. 4. The baby's head is almost crowning.

43. A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is fl exed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions.

43. 1. The obstetric conjugate is the shortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head. 2. When the fetal head is flexed, the diameter of the head is minimized. This is not, however, the obstetric conjugate. 3. There is no average dilation for the beginning of labor. 4. The physiological retraction ring is the area of the uterus that forms as a result of cervical effacement. It is not related to the obstetric conjugate. Other answers to other questions not on here 44. q 3 minutes 45. 90 seconds 46. 1. The contraction pattern is q 3 min × 90 sec. 2. The contraction pattern is q 3 min × 90 sec. 3. The contraction pattern is q 3 min × 90 sec.

47. A woman who is in active labor is told by her obstetrician, "Your baby is in the fl exed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

47. 1. A baby in the breech presentation may or may not be in the flexed attitude. 2. A baby in the horizontal lie may or may not be in the flexed attitude. 3. Engagement is unrelated to attitude. 4. When the baby's chin is on his or her chest, the baby is in the flexed attitude.

48. An ultrasound report states, "The fetal head has entered the pelvic inlet." How should the nurse interpret this statement? 1. The fetus is full term. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

48. 1. A full-term baby may still have yet to enter the pelvic inlet. 2. The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis. 3. The baby is physiologically unable to enter the true pelvis when in a horizontal lie. 4. The attitude of the baby is not discussed in the ultrasound statement.

5. While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a fl at surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed. Regional anesthesia Stage 1 of labor (cervical change to 10 centimeters dilation) Stage 2 of labor (full dilation to birth of the baby) Stage 3 of labor (birth of the baby to birth of the placenta) Station Surrogate Transition (phase 3) of the fi rst stage of labor Vaginal introitus Variability Variable deceleration

5. 1. With the palpation findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal position in not transverse. 2. The findings on palpation also indicate that the presentation is not vertex. 3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical. 4. The attitude is difficult to determine when performing Leopold maneuvers. Many obstetric assessments have a component that is sensual and a component that is an interpretation or concept. Leopold maneuvers are good examples. The nurse palpates specific areas of the pregnant abdomen but then must interpret or translate what he or she is feeling into a concept. For example, in the scenario presented, the nurse palpates a hard round mass in the fundal area of the uterus and must interpret that feeling as the fetal head. Similarly, the nurse palpates a soft round mass above the symphysis and must interpret that feeling as the fetal buttocks. With these findings and interpretations, the nurse will then realize that the fetal lie is vertical.

52. During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

52. 1. Flexion is one of the first of the cardinal moves of labor. 2. Internal rotation occurs while the baby is still in utero. 3 During extension, the baby's head is birthed. 4. The baby rotates externally after the birth of the head.

53. The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must the nurse perform at this time? 1. Place the client in the lateral recumbent position. 2. Carefully analyze the baseline data on the monitor tracing. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

53. 1. When assessing the variability of the fetal heart, the mother can be in any position. 2. The variability of the fetal heart rate is determined by analyzing the beat-to-beat fluctuations of the baseline rate. 3. Only after assessing a poor fetal monitor tracing would the nurse administer oxygen. 4. Variability is unrelated to fetal movement.

54. The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time? 1. Provide caring labor support. 2. Administer oxygen via tight-fi tting face mask. 3. Turn the woman on her side. 4. Apply the oxygen saturation electrode to the mother.

54. 1. Because the variability is moderate (6 to 25 bpm wide), the nurse can conclude that the baby is well and that caring labor support is indicated. 2. Because the variability is moderate (6 to 25 bpm wide), there is no need for the mother to receive oxygen. 3. Because the variability is moderate (6 to 25 bpm wide), there is no need to move the mother to another position. 4. Because the variability is moderate (6 to 25 bpm wide), there is no need to measure the mother's oxygen saturation.

55. After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this fi nding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

55. 1. Moderate variability is indicative of fetal health, not of hypoxia. 2. A change in variability indicates acidosis, not alkalosis. In this situation, there is no indication of acidosis. 3. During sleep cycles, fetal heart rate variability decreases. 4. Moderate variability is indicative of fetal health.

56. When would the nurse expect to see the fetal monitor tracing shown below? 1. During latent phase of labor. 2. During an epidural insertion. 3. During second stage of labor. 4. During delivery of the placenta.

56. 1. Early decelerations are rarely seen during the latent phase of labor. 2. Epidural insertion is not associated with early decelerations. 3. Early decelerations are frequently seen during the second stage of labor. 4. By the time the placenta is being delivered, the baby is already born.

57. When would the nurse expect to see the fetal heart changes noted on the fetal monitor tracing shown below? 1. During fetal movement. 2. After the administration of analgesics. 3. When the fetus is acidotic. 4. With poor placental perfusion.

57. 1. The fetal heart rate normally accelerates during fetal movement. 2. When analgesics are administered, the fetal heart rate variability drops and accelerations are rarely seen. 3. When a fetus is acidotic, the fetal heart rate variability drops and accelerations are rarely seen. 4. With poor placental perfusion, the fetal heart rate variability drops and accelerations are rarely seen.

58. A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

58. 1. The baby's heart rate should not exhibit variable decelerations after the mother is given pain-relieving medication. 2. The baby's heart rate should not exhibit late decelerations after the mother is given an analgesic. 3. Analgesics are central nervous system (CNS) depressants. The variability of the fetal heart rate, therefore, will be decreased. 4. The baby's heart rate is unlikely to exhibit transient accelerations after the mother receives analgesics.

59. The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. 2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Baseline of 140 to 142 with no obvious decelerations or accelerations.

59. 1. A baseline fetal heart rate (FHR) of 140 to 150 is a baseline with moderate variability, but V-shaped decelerations are variable decelerations. These are related to cord compression and are not normal. 2. A baseline FHR of 140 to 150 is a baseline showing moderate, or normal, variability. Decelerations that mirror contractions are defined as early decelerations. These are related to head compression and are expected during transition and second stage labor. 3. A baseline with beat-to-beat changes of only 2 bpm is defined as minimal variability. Also, there are late decelerations. Late decelerations are related to uteroplacental insufficiency. This situation is an obstetric emergency. 4. A baseline with beat-to-beat changes of only 2 bpm is defined as minimal variability. Even when no decelerations are noted, the nurse should be concerned when the FHR is showing minimal variability.

6. When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal examinations. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

6. 1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal examinations. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 4. The fetal heart pattern should be assessed every hour during the latent phase of a low-risk labor. It is not standard protocol to assess every 10 minutes. 5. The nurse should assess the fetal heart before the woman ambulates.

60. A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

60. 1. The fetal heart should be assessed every 5 minutes or less during the second stage of labor. 2. The woman should be encouraged to grunt during contractions. 3. The pulse should be assessed, but it is unnecessary to do so every 5 minutes. 4. There is no one pushing position that is required. Women may push while squatting, on hand and knees, or in a number of other positions.

61. A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

61. 1. Holding the breath for 20 seconds during each contraction can stimulate the Valsalva maneuver, which can lead to a sudden drop in blood pressure and fainting. 2. One cannot push and blow out at the same time. This will not facilitate the delivery of the baby. 3. Pushing should be done only during contractions, not between contractions. 4. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction.

62. A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's healthcare practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Continue to provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

62. 1. Bloody show and perineal bulging are normal findings. There is no need to notify the health care practitioner at this time. 2. Bloody show and perineal bulging are normal findings. The woman is not in need of immediate cardiovascular assessment. 3. Because this is a normal finding, the nurse should continue to provide labor support and encouragement. 4. Bloody show and perineal bulging are normal findings.. There is no need to administer oxygen or to change the woman's position.

63. A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

63. 1. Epidurals are a form of regional anesthesia. They are used to obliterate pain. 2. It is inappropriate to encourage the woman to receive an epidural at this time. 3. Because this woman is a multipara, the position is LOA, and the station is +3, this is an accurate statement. 4. It is inappropriate to encourage the woman to receive an epidural at this time.

64. A pregnant woman is discussing possible delivery options with a labor nurse. Which of the following client responses indicates that the woman understood the information? Select all that apply. 1. When the client states, "I am glad that deliveries can take place in a variety of places, including in the labor bed." 2. When the client says, "I heard that for doctors to deliver babies safely, it is essential that I lie on my back with my legs up." 3. When the client states, "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." 4. When the client says, "During diffi cult deliveries it is sometimes necessary to put a woman's legs up in stirrups." 5. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

64. 1, 3, 4, and 5 are correct. 1. This statement is true. A birth may take place in a variety of locations and positions, including sitting on a stool in the shower, kneeling while holding onto the back of the labor bed, or even while standing. 2. The nurse should provide additional information to this client. Many deliveries are performed safely in positions other than the lithotomy position. 3. If the fetus is in the posterior or transverse position, the woman may be encouraged to push while on her hands and knees. This may enable the baby to turn into the anterior position and the delivery may soon follow. 4. Many mothers deliver in their labor beds without stirrups. Some beds transform into delivery beds and some are regular hospital beds. Still others are double or queen-sized beds so that the father and/ or the delivering practitioner can also relax in the bed. When forceps or other interventions are needed for a delivery, however, stirrups may be required. 5. Midwives deliver their clients in a variety of positions, including the side-lying, squatting, and lithotomy positions, as well as when the clients are on their hands and knees.

65. During the third stage of labor, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts. 4. The uterine surface area dramatically decreases.

65. The order of change during the third stage of labor is: 3, 4, 1, 2. 3. The contraction of the uterus after delivery of the baby is the first step in the third stage of labor. 4. As the uterus contracts, its surface area decreases more and more. 1. A hematoma forms behind the placenta as the placenta separates from the uterine wall after the uterus has contracted and its surface area has decreased. 2. The membranes separate from the uterine wall after the placenta separates and begins to be born.

66. A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

66. 1. Considering the signs, this is an unlikely reason. 2. These are signs of placental delivery. 3. Considering the signs, this is an unlikely reason. 4. Cord bloods are obtained by the practitioner once the cord is cut. The clamp on the cord that is still attached to the placenta is released and blood is obtained from the cut cord.

67. A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

67. 1 and 3 are correct. 1. This is a sign of placental separation. 2. Once second stage is complete, the baby is no longer in utero. 3. This is a sign of placental separation. 4. Dilation and effacement are complete before second stage begins. 5. Rectal pressure is usually a sign of fetal descent. Once the second stage is complete, the baby is no longer in utero.

68. A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

68. 1. This comment would be consistent with a client in the latent phase of labor. 2. This comment is consistent with a woman in the transition phase of stage 1. 3. This comment could be made at a variety of times during the labor. 4. This comment is consistent with a woman in stage 2 labor.

69. A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

69. 1. The nurse would expect the woman to be 2 cm dilated. 2. At 4 cm, the woman is entering the active phase of labor. 3. At 8 cm, the woman is in the transition phase of labor. 4. At 10 cm, the woman is in the second stage of labor.

7. The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

7. 1. Palpating the sacral promontory assesses the obstetric conjugate, not the fetal station. 2. Station is assessed by palpating the ischial spines. 3. Palpating the cervix assesses dilation and effacement, not fetal station. 4. Palpating the symphysis pubis assesses the obstetric conjugate, not the fetal station.

70. A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following fi ndings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia. 4. Decreased respiratory rate.

70. 1. With pain and increased energy needs, the pulse rate often increases. 2. The blood pressure rises dramatically. 3. Although the woman is working very hard, her temperature should remain normal. 4. With pain and increased energy needs, the respiratory rate often increases.

71. A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the fi ndings to the primary healthcare practitioner? 1. The woman is at high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is at high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

71. 1. The woman is exhibiting no high-risk issues. 2. The woman is in early labor. There is no need for her to be hospitalized at this time. 3. The woman is exhibiting no high-risk issues. 4. The woman is in early labor, not active phase.

72. A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

72. 1. Talking and laughing are characteristic behaviors of the latent phase. 2. Back labor can be experienced during any phase of labor. 3. Women in the latent phase often do perform effleurage, but it can also be performed during other phases of labor. 4. A woman in the latent phase might go to the bathroom but defecating is not indicative of the first phase of labor.

73. A G1 P0, 8 cm dilated, is to receive pain medication. The healthcare practitioner has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesic. Which of the following medications would the nurse expect to be ordered in conjunction with the analgesic medication? 1. Seconal (secobarbital). 2. Phenergan (promethazine). 3. Stadol (butorphanol). 4. Tylenol (acetaminophen).

73. 1. Seconal is a barbiturate sedative. It is not used as an analgesic potentiator. 2. Phenergan acts to reduce nausea and vomiting as well as to reduce allergic response. 3. Stadol is a narcotic analgesic. It would not be administered to a woman already receiving an analgesic. 4. Tylenol is a nonsteroidal anti-inflammatory drug that is ineffective as an analgesic in labor.

74. On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

74. 1. It is recommended that women delay pushing until they feel the urge to push. 2. There is no indication for oxygen in this scenario. 3. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis to birth the baby. 4. There is no indication of maternal compromise in this scenario.

75. A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

75. 1. The woman should be helped into the fetal position. 2. The lithotomy position is inappropriate. 3. The Trendelenburg position is inappropriate. 4. The lateral recumbent position is inappropriate.

76. Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1,000 mL of Ringer's lactate. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.

76. 1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should receive an order to infuse Ringer's lactate before the woman is given regional anesthesia. 3. It is not appropriate to place the woman in the Trendelenburg position. 4. The blood pressure will need to be monitored every 5 minutes for 15 minutes after administration of the anesthesia but not before. 5. The nurse should ask the woman to empty her bladder.

77. Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following side effects? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

77. 1. It is unlikely that the woman will experience adverse feelings in her lower extremities. 2. Hypotension is a very common side effect of regional anesthesia. 3. The epidural does not enter the spinal canal. There will be no change, higher or lower, in the central venous pressure. 4. Fetal heart accelerations are positive signs. These are not adverse findings.

78. A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

78. 1. The temperature does not need to be assessed immediately after the epidural insertion. 2. A wedge should be placed under one side of the woman. 3. There is no indication that a blanket roll needs to be placed under the woman's feet at this time. 4. It is not necessary for the nurse to assess the pedal pulses at this time.

79. The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? 1. Spontaneous fetal movement. 2. Fetal heart acceleration. 3. Increase in fetal heart variability. 4. Resolution of late decelerations.

79. 1. Fetal movement is noted during labor, but it is not directly related to the fetal scalp stimulation test. 2. The fetal heart should accelerate in response to scalp stimulation. 3. The variability does not change in direct response to the fetal scalp stimulation test. 4. Late decelerations are related to uteroplacental insufficiency. The fetal scalp stimulation test will not affect a late deceleration pattern.

8. The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A fl at object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these fi ndings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

8. 1. The nurse's findings upon performing Leopold maneuvers indicate that the fetus is in the left occiput anterior (LOA) position—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis. 2. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the left sacral posterior (LSP) position; in that position, the fetus's buttocks (S or sacrum) are facing toward the mother's left posterior (LP), a hard round mass is felt in the fundal region, and a soft round mass is felt above the symphysis. 3. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the right mentum anterior (RMA) position; in that position, the fetus's face (M or mentum) is facing toward the mother's right anterior (RA) and small objects are felt on the right of the mother's abdomen with a fl at area felt on the mother's left side. 4. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the right sacral posterior (RSP) position; in that position, the fetus's sacrum (S) is facing the mother's right posterior (RP) and a hard round mass is felt in the fundal region while a soft round mass is felt above the symphysis.

80. The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 g/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30.

80. 1. Oxygen saturations are noninvasive assessments, whereas fetal scalp sampling assessments are performed on blood obtained from the fetal scalp. Fetal oxygen saturation levels are well below those seen in extrauterine life—approximately 50% to 75%. 2. Normal fetal hemoglobin levels are well above those seen in extrauterine life—14 to 20 g/dL. 3. This fetal glucose level is indicative of maternal hyperglycemia. 4. This fetal pH value is within normal limits.

81. Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? 1. Apply heat to the woman's back. 2. Inquire regarding the woman's pain level. 3. Make sure that the woman's head is covered. 4. Accept the woman's loud verbalizations.

81. 1. Many Chinese believe that labor is a "hot" period. Applying heat at this time would be culturally insensitive. 2. It is important to inquire about the pain level of all women in labor, especially those from the Asian culture. 3. Head covering is important for observant Jewish women and Muslim women but is not usually important for Chinese women. 4. It is very uncommon for Chinese women to be very verbal during labor.

82. A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization? 1. Syrian woman. 2. Chinese woman. 3. Russian woman. 4. Greek woman.

82. 1. Muslim women, who are often from Arabic countries, like Syria, are expected to keep their heads covered at all times. 2. Chinese women do not usually request that their heads be covered. 3. Russian women do not usually request that their heads be covered unless they are observant Jews. 4. Greek women do not usually request that their heads be covered.

83. The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care? 1. Encourage the father to hold his partner's hand during labor. 2. Ask the woman if she would like to speak with her priest. 3. Provide the woman with a long-sleeved hospital gown. 4. Place an order for the woman's postpartum vegetarian diet.

83. 1. An Orthodox Jewish man is forbidden by Jewish law from touching his mate whenever she is experiencing vaginal discharge. 2. The religious leader of the Jewish people is the rabbi. A priest is the religious leader of Catholics and some other Christian sects. 3. Observant Jewish women are expected to have their elbows covered at all times. A long-sleeved gown, therefore, should be provided for them. 4. Observant Jewish women will follow a kosher diet that may or may not be vegetarian.

84. Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply. 1. Engage in sexual intercourse. 2. Ingest evening primrose oil. 3. Perform yoga exercises. 4. Eat raw spinach. 5. Massage the breast and nipples.

84. 1, 2, and 5 are correct. 1. Nurse midwives sometimes recommend that women at full term engage in sexual intercourse to stimulate labor. 2. Ingesting primrose oil is also sometimes recommended. Primrose oil is believed to help ripen the cervix. 3. Exercise should be encouraged throughout pregnancy, but it is not used for induction. 4. Raw spinach is an excellent source of iron as well as a source of calcium and fiber. It is, however, not used for induction. 5. Nipple and breast massage is sometimes recommended to help induce labor.

85. The nurse is providing acupressure for pain relief to a woman in labor. Where is the best location for the acupressure to be applied? Select all that apply. 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. At the top one-third of the sole of the foot. 5. Below the medial epicondyle of the elbow.

85. 3 and 4 are correct. 1. The malleolus of the wrist has not been shown to reduce the pain of labor contractions. 2. The area above the patella of the knee has not been shown to reduce the pain of labor contractions. 3. Pressure applied on the medial surface of the lower leg has been shown to lessen the pain of labor. 4. Pressure applied to the depression at the top one-third of the sole of the foot has been shown to lessen the pain of labor. 5. The area below the elbow has not been shown to reduce the pain of labor contractions.

86. To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil.

86. 1. Squatting is an alternate position for delivery, but it is not used to decrease perineal tearing. 2. Pushing the fetal head against the perineum is the cause of perineal tearing. 3. Pushing the fetal head against the perineum is the cause of perineal tearing. 4. Massaging of the perineum with mineral oil does help to reduce perineal tearing.

87. The physician writes the following order for a newly admitted client in labor: Begin a 1,000 mL IV of D5 1/2 NS at 150 mL/hr. The IV tubing states that the drop factor is 10 gtt/mL. Please calculate the drip rate to the nearest whole. ______ gtt/min

87. 25 gtt/min Standard method formula for drip rate calculations: Volume in mL Time in minutes Drop factor 150 mL 60 min 10 gtt/mL = 150 6 × × 150 6 = 25 gtt/min Dimensional analysis method formula: Volume ordered Drops Time conversion Volume conversion = Infusion rate Time for (gtt/min) infusion per 1 mL in minutes (if needed) (if needed) 150 mL 10 gtt = 25 gtt/min 60 min 1 mL

88. The healthcare practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? Calculate to the nearest hundredth. ____ mL

88. 0.25 mL Standard formula for calculating the volume of medication to be administered: Known dosage : known volume = desired dosage : desired volume 2 mg : 1 mL = 0.5 mg : x mL 2 mg x = 0.5 mg x = 0.25 mL Dimensional analysis method for calculating the volume of medication to be administered: Known volume Desired dosage = Desired volume Known dosage 1 mL 0.5 mg = 0.25 mL 2 mg

89. The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station -2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

89. 1. The cervix is thin. 2. There is nothing in the scenario that suggests that the membranes are bulging. 3. At − 2 station, the head is well above the ischial spines. 4. The cervix is dilated 5 cm (or approximately 2 inches). The nurse would, therefore, not feel a closed cervix.

9. A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

9. 1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates progression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 3. The amniotic sac can rupture at any time. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The gravida's ability to work with her labor is more dependent on her level of pain and her preparation for labor than on the phases and/ or stages of labor.

90. It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fl uids for you whenever you would like them, though."

90. 1. Laboring clients are allowed to eat by some practitioners. Midwives are more likely to allow eating than physicians. 2. This is a very negative statement that does not answer the client's question. 3. It is unlikely that the woman will eat at established meal times. Plus, a regular diet is rarely given to laboring clients, even by midwives. 4. This is the best response.

91. In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider ordered self-administered inhaled nitrous oxide (N 2 O) in a N 2 O 50% / O 2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? Select all that apply. 1. Nausea. 2. Hypotension. 3. Dehydration. 4. Light-headedness. 5. Late fetal heart decelerations.

91. 1 and 4 are correct. 1. Both nausea and vomiting are side effects of nitrous oxide administration. 2. When administered in a 50%/50% concentration, nitrous oxide has not been shown to cause hypotensive episodes. 3. Patients using N 2 O are not at high risk for dehydration. 4. Patients often do exhibit light-headedness when using N 2 O. 5. One important advantage of N 2 O over other labor pain-relieving methods is the fact that the fetus, and the baby after birth, rarely exhibit adverse responses to the medication.

92. Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting, too." The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-relieving methods? 1. Epidural. 2. Nitrous oxide. 3. Narcotic analgesic. 4. Spinal.

92. 1. Although epidural anesthesia will relieve the client's pain, it will not act to reduce the client's fears. 2. During labor, inhaled nitrous oxide exerts both a pain-relieving action as well as an anxiety-reducing action. 3. Although a narcotic analgesic will reduce the client's pain, it will not act to reduce the client's fears. 4. Although used frequently for delivery, spinal anesthesia is rarely used during labor for two important reasons: (1) It paralyzes the patient, resulting in her inability to move until the medication is fully metabolized and (2) once the medication is metabolized, if the client is still in pain, there is no way to readminister the medication.

93. A laboring woman and two men enter the labor suite. One of the men states, "We and our surrogate are here for our baby's delivery. Where should we go?" Which of the following responses by the nurse would be appropriate? 1. Congratulate the surrogate on the gift she is giving the gay couple. 2. Remind the men that labor and delivery experience is very stressful. 3. Remind the men that the woman is the baby's mother. 4. Ask the laboring woman whom she would like to be with her during labor.

93. 1. Although it is true that the surrogate will surrender her baby to the gay couple, that is not the appropriate response for the nurse to give. 2. Although it is true that the labor and delivery experience is very stressful, that is not the appropriate response for the nurse to give. 3. Because the woman is carrying the baby and will birth the baby, from a biological perspective, the woman is the baby's mother. That is, however, not the appropriate response for the nurse to give. 4. The nurse should ask the laboring woman whom she would like to be with her during labor.