Chapter 12: Process of Birth

16. A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?

The acme

26. To determine if the client is in true labor, the nurse would assess for changes in:

cervical dilation.

27. The health care provider for a laboring patient makes the following entry into the patient's record: 3/50%/-1. What instruction will the nurse implement with the patient?

"Breathe with me slowly, in through your nose and out through your mouth."

29. The primipara at 39 weeks' gestation states to the nurse, "I can breathe easier now." What is the nurse's best response?

"That process is called lightening. Do you have to urinate more frequently?"

10. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?

Flexion

12. A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long?

8 to 10 hours

19. Which maternal factor may inhibit fetal descent?

A full bladder

37. Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) a. A gush of blood appears. b. The uterus rises upward in the abdomen. c. The fundus descends below the umbilicus. d. The cord descends further from the vagina. e. The uterus becomes boggy and soft, with an elongated shape.

A gush of blood appears. The uterus rises upward in the abdomen. The cord descends further from the vagina.

14. A client whose cervix is dilated to 5 cm is considered to be in which phase of labor?

Active phase

33. A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.)

Ask her if her if she thinks that her membranes have ruptured. Tell her to come into the hospital for evaluation.

8. The nurse is assessing the duration of a client's labor contractions. Which action does the nurse implement to assess the duration of labor contractions?

Assess from the beginning to the end of each contraction.

20. Which assessment finding would cause a concern for a client who had delivered vaginally?

Client complains of fingers tingling

21. Which clinical findings would be considered to be normal for a preterm fetus during the labor period?

Baseline tachycardia

9. Which event is the best indicator of true labor?

Cervical dilation and effacement

2. The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction?

Diminishes as the spiral arteries are compressed

5. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?

Engagement

31. A laboring patient states to the nurse, "I have to push!" What is the next nursing action?

Examine the patient's cervix for dilation.

34. A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.)

In true labor, the cervix begins to dilate In true labor, contractions often resemble menstrual cramps during early labor In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

3. The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions?

Maternal circulating blood volume increases temporarily during contractions.

38. The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.)

Natural oxytocin in conjunction with other substances plays a role. Stretching, pressure, and irritation of the uterus and cervix increase.

22. On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?

Notify the health care provider

30. The nurse assess a laboring patient's contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern?

Stage 1, active phase

36. The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) a. Offer the client a warm blanket. b. Place an ice pack on the perineum. c. Massage the uterus if it is boggy. d. Delay breastfeeding until the client is rested. e. Explain to the client that the lochia will be light pink in color.

Offer the client a warm blanket. Place an ice pack on the perineum. Massage the uterus if it is boggy.

28. The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient?

On her left side

32. After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the best nursing action in response to this statement?

Place a warm blanket over the patient.

35. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)

Powers Passage Passenger Psyche

15. The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase?

The client is requesting pain medication.

13. A client just delivered a baby by the vaginal route. The client asks the nurse why the baby's head is not round, but oval. Which explanation should the nurse give to the client?

This results from molding.

1. The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that he's doing now, he could tell her when the contractions are:

at their acme

23. An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is

bloody mucus drainage from vagina

24. If a notation on the client's health record states that the fetal position is LSP, this means that the:

buttocks are in the left posterior quadrant of the pelvis

25. The assessment finding which indicates that the client is in the active phase of the first stage of labor is

dilation of 5 cm

7. Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have:

increased blood volume.

11. An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates:

lightening

6. The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by:

pulling the cervix over the fetus and amniotic sac.

4. Uncontrolled maternal hyperventilation during labor results in:

respiratory alkalosis

18. The primary difference between the labor of a nullipara and that of a multipara is:

total duration of labor.

17. A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with:

umbilical cord compression.