Chapter 12 Questions

A pregnant patient who is nearing her due date informs the nurse that she would like a vaginal delivery. The nurse observes in the medical records that the presenting part is the sacrum. What does the nurse tell the patient? 1 "Vaginal delivery may not be possible." 2 "There will be no complications during labor." 3 "You may have to lose weight for a safe delivery." 4 "The infant may have congenital physical defects

1 If the presenting part of the fetus is the sacrum, it indicates a breech presentation. Vaginal delivery of a fetus in breech position carries increased risks and it is more likely that the patient will have to have a caesarean delivery. It is inaccurate to inform the patient that there will be no complications during the birth, because this is not something that the nurse can predict. A breech presentation does not indicate that the patient needs to lose weight. Environmental and biologic factors are associated with congenital defects.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun is what? 1 Progressive uterine contractions with cervical change 2 Lightening 3 Rupture of membranes 4 Passage of the mucus plug (operculum

1 Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucus plug is a premonitory sign indicating that the onset of labor is getting closer.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? 1 The fetal presenting part is 1 cm above the ischial spines. 2 Effacement is 4 cm from completion. 3 Dilation is 50% completed. 4 The fetus has achieved passage through the ischial spines.

1 Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

The nurse is assessing a patient in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? 1 Latent phase 2 Active phase 3 Transition phase 4 Descent phase

1 The patient is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase or active pushing phase occurs in the second stage of labor. In this phase, the patient has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.

During a sterile vaginal examination, the nurse finds that the fetal position is ROA. What is the presenting part of the fetus? 1 Occiput 2 Sacrum 3 Scapula 4 Mentum

1 The presenting part of the fetus is the part that appears first during the labor. The fetal position refers to the presenting part in relation to the mother's pelvis. The position is denoted by a three-part abbreviation. In this case, the letters ROA stand for right, occiput, and anterior. It means that the occiput is the presenting part and is located in the right anterior quandrant of the maternal pelvis. Sacrum will be denoted by the letter S. Scapula (shoulder) is denoted by Sc. Mentum (chin) is denoted by the letter M.

With regard to primary and secondary powers, the maternity nurse should understand what? 1 That primary powers are responsible for effacement and dilation of the cervix 2 That effacement generally is well ahead of dilation in women giving birth for the first time; they are less together in subsequent pregnancies 3 That scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation 4 That pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs

1 The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in first-time mothers; they are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

When is the best time to determine the station of the presenting part in a pregnant patient? 1 When the labor begins 2 A week before the labor 3 During the fourth stage of labor 4 At the end of the third stage of labor

1 The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Birth is imminent when the presenting part is at +4 cm to +5 cm below the spine. A week before the labor is too early to determine the station because fetal descent has usually not begun. The delivery of the placenta occurs in the fourth stage of labor. Therefore, the birth process is already complete by this stage. The third stage involves the birth of the infant and ends with the expulsion of the placenta. Therefore, it is ineffective to determine the station at that point.

Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1 A return of urinary frequency as a result of increased bladder pressure 2 Persistent low backache from relaxed pelvic joints 3 Stronger and more frequent uterine (Braxton Hicks) contractions 4 A decline in energy as the body stores up for labor 5 Uterus sinking downward and forward in first-time pregnancies

1,2,3,5 After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term

The nurse is assessing a pregnant patient who is due in 2 weeks. Which signs and symptoms preceding labor may the nurse expect to see in the patient? Select all that apply. 1 Loss of weight 2 Pain in the groin 3 Persistent low backache 4 Loss of energy 5 Blood-tinged cervical mucus

1,2,3,5, The pregnant patient may have a weight loss of 0.5 to 1.5 kg in the days preceding labor, due to water loss from electrolyte shifts, caused by changes in estrogen and progesterone levels. Pain in the groin and persistent low backache may occur due to the relaxation of the pelvic joints. The extreme congestion of the vaginal mucous membranes may cause blood-tinged cervical mucus. A surge of energy is a common phenomenon in a pregnant patient preceding labor

Which are the factors that affect the onset of labor? Select all that apply. 1 Increasing intrauterine pressure 2 Increasing estrogen levels 3 Decreasing oxytocin levels 4 Decreasing progesterone levels 5 Decreasing prostaglandin levels

1,2,4 Increasing intrauterine pressure, increasing estrogen levels, and decreasing progesterone levels affect the onset of labor. Increasing intrauterine pressure is associated with increasing myometrial irritability. This is caused by increasing concentrations of estrogen and decreasing progesterone levels. Oxytocin and prostaglandin levels are known to increase during the onset of labor.

Which fetal attitude is seen in general flexion? Select all that apply. 1 The chin is flexed on the chest. 2 The legs are flexed at the knees. 3 The fetal head is extended. 4 The thighs are flexed on the abdomen. 5 The arms are crossed over the thorax.

1,2,4,5 Attitude or posture refers to the relation of the fetal body parts to one another. The attitude of general flexion is seen in most pregnancies. The chin is flexed on the chest, as the back of the fetus is rounded. As a result, the legs are flexed at the knees, and the thighs are flexed on the abdomen. The arms are crossed over the thorax, and the umbilical cord lies between the arms and legs. An extended fetal head indicates a deviation from the normal attitude that may cause difficulties during childbirth.

A patient has just vaginally delivered a 6-lb baby girl and the placenta. What does the fourth stage of labor entail? Select all that apply. 1 It is a crucial time for mother and newborn. 2 The fourth stage of labor is delivery of the fetus. 3 The fourth stage of labor includes delivery of the placenta. 4 The fourth stage of labor includes the first 1 to 4 hours after birth. 5 During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. 6 Mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members.

1,4,5,6 The fourth stage of labor is a crucial time for the mother and the newborn; it includes the first 1 to 2 hours after birth. During this time maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. The mother and baby are not only recovering from the physical process of birth, but are also becoming acquainted with each other and additional family members. The second (not fourth) stage of labor is delivery of the fetus. The third (not fourth) stage of labor includes delivery of the placenta.

Place the following cardinal movements in the order in which they occur as a fetus passes through the birth canal during a vertex-presentation birth. A. _____ Flexion B. _____ External rotation C. _____ Descent D. ____ Extension E. _____ Restitution F. _____ Internal rotation G. ____ Expulsion

1. Descent 2. Flexion 3. Internal Rotation 4. Extension 5. Restitution 6. External Rotation 7. Expulsion The order of the cardinal movements (mechanisms of labor) occur as follows: descent, flexion, internal rotation, extension, restitution, external rotation, expulsion.

When assessing a patient for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? 1 It is the part above the brim of the bony pelvis. 2 It is movable in the latter part of the pregnancy. 3 It has three planes: the inlet, midpelvis, and outlet. 4 It is ovoid and bound by pubic arch anteriorly

2 The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly

Concerning the third stage of labor, nurses should be aware of what? 1 The placenta eventually detaches itself from a flaccid uterus. 2 The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered. 3 It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. 4 The major risk for women during the third stage is a rapid heart rate.

2 The duration of the third stage of labor may be short. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

The nurse is assisting the health care provider with a patient in labor. The nurse concludes that the placental blood flow is reduced. What assessment finding would lead the nurse to conclude this? 1 Increased maternal blood pressure 2 Prolonged contractions 3 Impaired fetal respiratory movement 4 Slow decrease in progesterone levels

2 The nurse is assisting the health care provider with a patient in labor. The nurse concludes that the placental blood flow is reduced. What assessment finding would lead the nurse to conclude this? 1 Increased maternal blood pressure 2 Prolonged contractions 3 Impaired fetal respiratory movement 4 Slow decrease in progesterone levels

The nurse is assisting a patient in labor. What neurologic changes does the nurse expect in the laboring patient? 1 Decreased pain threshold 2 Amnesia and sedation 3 Increased perception of pain 4 Patient elated between contractions

2 The patient experiences amnesia between contractions in the second stage of labor. Endogenous endorphins produced by the body cause sedation. This also raises the pain threshold. Pressure of the presenting part causes physiologic anesthesia of the perineal tissues. This decreases the perception of pain. At the start of labor, the patient may be euphoric. Euphoria first gives way to increased seriousness. Second, it gives way to amnesia between contractions. Finally, it leads to elation or fatigue after giving birth.

The nurse is briefing a patient who is pregnant for the first time about "lightening." Which statement should the nurse mention to describe lightening to the patient? 1 Occurs when true labor is in progress 2 Allows the patient to breathe more easily 3 Decreases the pressure on the bladder 4 Leads to decreased urinary frequency

2 When the fetal head descends into the true pelvis during "lightening," the patient will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency.

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine 2 1 cm above the ischial spine 3 at the level of the ischial spine 4 1 cm below the ischial spine

2 When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

Nurses can help their patients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Select all that apply. 1 Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours 2 Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours 3 Lull: no contractions; dilation stable; duration of 20 to 60 minutes 4 Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours 5 Full cervical dilation marks the end of the first stage of labor

2, 5 The active stage is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes. Full cervical dilation marks the end of the first stage of labor. No official "lull" phase exists in the first stage.

The nurse is assisting a pregnant patient in labor. What instructions should the nurse give to the patient to promote comfort? Select all that apply. 1 "You should cough frequently." 2 "Breathe with your mouth open." 3 "Lie down in the lateral position." 4 "Lie in the supine position in bed." 5 "Lie in the semi-Fowler's position."

2,3,5 The nurse helps the pregnant patient during labor. This includes teaching the patient relaxation techniques. The nurse teaches the patient to keep the mouth open during exhalation to allow air to easily leave the lungs. Placing the patient in a semi-Fowler's or lateral position is helpful during labor. Therefore the nurse should instruct the patient to maintain the lateral or semi-Fowler's position with a lateral tilt. Asking the patient to cough frequently would increase the intraabdominal pressure of the patient and would make the patient uncomfortable. Having the patient lie down in a supine position during labor may cause orthostatic hypotension. Therefore the nurse should instruct the patient to lie down in a position other than supine.

What behavior does the nurse expect in a patient who is in the transition phase during the first stage of labor? 1 The patient remains calm and silent. 2 The patient doubts her ability to control pain. 3 The patient vomits. 4 The patient's attention is directed inward.

3 A patient in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The patient may hyperventilate, resulting in nausea and vomiting. The patient may remain calm and silent in the latent phase of uterine contractions, because the urge to bear down is not too strong in this phase. During the active stage of labor, the patient may become doubtful of her ability to control pain. The patient's attention is directed inward in the active phase of the first stage of labor.

What does the nurse know that occurs in the second stage of labor, the descent phase? 1 The amniotic membranes rupture. 2 The cervix cannot be felt during a vaginal examination. 3 The woman experiences a strong urge to bear down. 4 The presenting part is below the ischial spines.

3 During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation

The nurse assesses a fetus as being in the cephalic presentation. What does the nurse mean by the term "fetal presentation"? 1 The relation of the presenting part to the mother's pelvis 2 The relation of the fetus's and mother's spine 3 The part of the fetus that enters the pelvic inlet first 4 The relation of the fetal body parts to one another

3 Fetal presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. In a cephalic presentation, the fetal head enters the pelvic inlet first. Fetal position is the relationship of the reference point on the presenting part of the fetus to the four quadrants of the mother's pelvis. The fetal lie is the relation of the long axis or spine of the fetus to the long axis or spine of the mother. The fetal attitude is the relation of the fetal body parts to one another in utero.

Which hormone produced by the fetus is believed to initiate labor? 1 Insulin 2 Estriol 3 Cortisol 4 Thyroxine

3 The adrenal cortex is formed during the 6th week of the gestational period and produces hormones by the 8th or 9th week. The fetus produces higher amounts of cortisol as the due date gets closer. This is believed to aid in initiating labor by decreasing the maternal progesterone and stimulating prostaglandin production. Insulin, which helps regulate glucose in the fetus, is produced by the islets of Langerhans of the pancreas. Estriol is a type of estrogen hormone secreted by the placenta that stimulates uteroplacental growth. Thyroxine is a thyroid hormone produced in the fetus; thyroxine does not easily cross the placenta.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

3 The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse verifies her understanding of the instructions when the woman makes what statement? 1 "True labor contractions will subside when I walk around." 2 "True labor contractions will cause discomfort over the top of my uterus." 3 "True labor contractions will continue and get stronger even if I relax and take a shower." 4 "True labor contractions will remain irregular but become stronger."

3 True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically, the contractions often stop with walking or a change of position.

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe what? 1 Weight gain of 1 to 3 lb 2 Quickening 3 Fatigue and lethargy 4 Bloody show

4 Passage of the mucus plug (operculum), also termed pink/bloody show, occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lb. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.

The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part? 1 -1 2 +1 3 +3 4 +5

4 Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm. When the lowermost portion of the presenting part is 1 cm above the spine, it is noted as minus (-)1. When the presenting part is 1 cm below the spine, the station is said to be plus (+)1. At +3, the presenting part is still descending the birth canal. Birth is imminent when the presenting part is at +4 to +5 cm

A pregnant woman at 40 weeks of gestation asks the nurse what factor initiates labor. What is the nurse's best response? 1 "Cervical dilation is the first step in initiating the labor process." 2 "Labor begins as a result of the increased secretion of oxytocin." 3 "One factor is higher progesterone levels, which we can mimic synthetically if labor doesn't begin soon." 4 "The exact mechanisms are unknown, but we do know that the fetus plays a role in secreting hormones that contribute to the initiation of labor."

4 The nurse's best response is, "The exact mechanisms are unknown, but we do know that the fetus plays a role in secreting hormones that contribute to the initiation of labor." Cervical dilation is not the first step in initiating the labor process. The cervix can dilate and contract throughout labor. Increased secretion of natural oxytocin appears to maintain labor once it has begun. Oxytocin alone does not appear to start labor but may play a part in labor's initiation in conjunction with other substances. The ratio of maternal estrogen to progesterone changes so that estrogen levels are higher than progesterone levels. Prostaglandins can be mimicked synthetically

During the vaginal examination of a patient in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation does the nurse recognize? 1 Cephalic 2 Frank breech 3 Complete breech 4 Shoulder

4 The presenting part can be defined as that part of the fetus that lies closest to the internal os of the cervix. In the shoulder presentation, the presenting part is the scapula. In a cephalic presentation, the presenting part is usually the occiput. In a breech presentation, the presenting part is the sacrum. The sacrum is the presenting part in a frank breech presentation. The sacrum and feet are the presenting parts in a complete breech presentation.

A nurse assesses a newborn as follows: heart rate is 112 beats/minute; respiratory effort: slow, irregular, with a weak cry; muscle tone: some flexion of the extremities; reflex irritability: grimace; color: pink. What Apgar score does the nurse give this infant?

7 Heart rate: 2; respiratory effort: 1; tone: 1; reflex irritability: 1; color: 2; total = 7

The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement. 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

A, B, C.

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 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, B, D rationale: Four Signs of Placental Separation - uterus has a spherical shape uterus rises upward in the abdomen the cord descends further from the vagina a gush of blood appears

The perinatal nurse is describing the process of fetal engagement to a group of first-time parents in a prenatal class. The nurse explains that in primigravidas, the usual time for engagement to occur is which of the following? A. 2 weeks before the due date B. 4 weeks before the due date C. 6 weeks before the due date D. During labor

A. 2 weeks before the due date Engagement is said to have occurred when the widest diameter of the fetal presenting part has passed through the pelvic inlet. In primigravidas, engagement usually occurs approximately 2 weeks before the due date. In multiparas, engagement may occur many weeks before the onset of labor, or it may take place during labor.

The nurse in the birthing unit is aware that according to the Emergency Medical Treatment and Active Labor Act (EMTALA), pregnant women should receive care for problems such as which of the following? (Select all that apply.) A. A history of recent trauma B. Contractions that occur 20 minutes apart C. Decreased fetal movement D. Rupture of the membranes E. Sexually transmitted infections

A. A history of recent trauma C. Decreased fetal movement D. Rupture of the membranes The federal regulation known as the Emergency Medical Treatment and Active Labor Act (EMTALA) was created to ensure that all women receive emergency treatment or active labor care whenever such treatment is sought. The nurse who is working in a birthing unit must be familiar with the full range of responsibilities included in the EMTALA regulations: (1) provide services to pregnant women when an urgent pregnancy problem such as labor, rupture of the membranes, decreased fetal movement, or recent trauma is experienced; and (2) fully document all relevant information to include assessment findings, interventions implemented, and the patient's response to the care provided. Treatment would not be required for women whose contractions are 20 minutes apart or who may have sexually transmitted infections.

A nurse is caring for a new mother during the fourth stage of labor and assesses the following: patient has soaked two peri-pads in 45 minutes, pulse is 118 beats/minute, and blood pressure is 90/62 mm Hg. Which action by the nurse is most important? A. Assess the firmness of the patient's uterus. B. Document the findings and reassess in 15 minutes. C. Encourage the woman to attempt breastfeeding. D. Escort the woman to the bathroom to void.

A. Assess the firmness of the patient's uterus. Hypotension, tachycardia, excessive bleeding (more than one peri-pad in the first hour), and a boggy, noncontracting uterus are all danger signs of postpartum hemorrhage. Based on this woman's signs and symptoms, the nurse should assess her uterus and, if necessary, begin uterine massage. Documentation needs to be thorough, but further action is needed. Breastfeeding does stimulate the uterus, but this action is not the priority in a possible emergent situation. A hypotensive woman should not be ambulated.

A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first? A. Assess the maternal temperature and call the primary care provider. B. Document the findings in the patient's chart. C. Have the woman get up and walk or change position. D. Perform a vaginal exam to assess for cord compression.

A. Assess the maternal temperature and call the primary care provider. Causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal medications (such as parasympathetic drugs and tocolytic drugs), infection, fetal anemia, and maternal hyperthyroidism. The nurse should quickly assess the maternal temperature and call the provider, as the tocolytic medication may need to be slowed or stopped. The findings do need to be documented, but further action is needed. The woman should not get up and walk, as this will further stimulate the fetus. Checking for cord compression is an important intervention with fetal bradycardia.

What important nursing action occurs right after the third stage of labor? A. Assess the placenta for complete expulsion. B. Assist the woman with effective pushing. C. Provide a lactation consultation if desired. D. Warm the baby and place it in an incubator.

A. Assess the placenta for complete expulsion. The third stage of labor is the time between the birth of the baby until the complete delivery of the placenta. An important nursing action is to assure that the entire placenta has been delivered. There is no need to assist with pushing as the baby has already been born. This is a good time to facilitate bonding and to attempt breastfeeding if desired, but too early to initiate a lactation consultation. The stable baby should be placed on the mother's abdomen.

A woman arrives at the birthing unit complaining of frequent strong contractions that begin in her back and cannot be relieved by walking or changing positions. What action by the nurse is most appropriate? A. Assess the woman for rupture of membranes. B. Immediately notify the woman's primary care provider. C. Reassure the woman and send her home. D. Review the signs of true labor with the woman.

A. Assess the woman for rupture of membranes. Distinguishing true labor from false labor can be difficult. True labor contractions occur with regularity, increased in frequency and duration, and usually begin in the woman's lower back and radiate to the abdomen. Based on the woman's description, the contractions likely are indicative of true labor, so she should be assessed further, including assessment for rupture of membranes. There is no urgent need to notify her primary care provider until further assessment is completed. She should not be sent home, nor does she need more education on the signs of true labor.

A nurse is assisting with an amnioinfusion. What critical nursing actions are included in this procedure? (Select all that apply.) A. Assessing the maternal temperature B. Assembling equipment C. Documenting fluid exiting the vagina D. Maintaining sterile technique E. Monitoring the fetal heart rate

A. Assessing the maternal temperature B. Assembling equipment C. Documenting fluid exiting the vagina E. Monitoring the fetal heart rate The critical nursing actions during this procedure are assembling the equipment; monitoring the fetal heart rate, contraction status, and maternal temperature; and verifying and documenting that the infused fluid exits the vagina. The nurse is not performing the procedure; it is up to the provider to maintain sterile technique. Of course the nurse should be vigilant that sterile technique is not breached.

The nurse is assessing a woman in labor. What techniques are vital for the nurse to use during this assessment? (Select all that apply.) A. Auscultation B. Inspection C. Interviewing D. Percussion E. Palpation

A. Auscultation B. Inspection C. Interviewing E. Palpation The nurse uses the skills of interviewing, inspection (observation), palpation, and auscultation to assess the woman in labor. Percussion is not generally used in this assessment.

The nurse instructs the pregnant woman to report any rupture of the membranes along with a description of the fluid. Which of the following would the nurse evaluate as normal amniotic fluid? (Select all that apply.) A. Clear liquid B. Contains white specks C. Presence of lanugo D. Slight ammonia odor E. Yellow-greenish color

A. Clear liquid B. Contains white specks C. Presence of lanugo Amniotic fluid should be clear and odorless. It may contain white specks and/or fetal hair (lanugo). Yellowish-green tinged fluid may indicate infection or the presence of meconium.

A woman with a history of two stillbirths is in the active phase of the first stage of labor in the high-risk OB unit. How often should the nurse anticipate monitoring fetal heart tones (FHTs)? A. Continuously B. Every 5 minutes C. Every 15 minutes D. Every 30 minutes

A. Continuously Women with certain complications, including a history of stillbirth, a high-risk pregnancy (preeclampsia-eclampsia, placenta previa, abruptio placentae, multiple gestations, prolonged or premature rupture of the membranes), induction with oxytocin, or a problem with FHT, should have FHT monitored continuously.

The nurse assessing a woman in the third stage of labor would expect which of the following findings? (Select all that apply.) A. Cramping as the placenta delivers B. Mother crying or feeling relieved C. Presence of lochia rubra with small clots possible D. Uterus rises upward E. Vital signs returning to prelabor values

A. Cramping as the placenta delivers B. Mother crying or feeling relieved D. Uterus rises upward During the third stage of labor, the mother may experience cramping as the placenta is expelled, after which the uterus will rise upward. The mother may cry or express relief that labor is over. Lochia rubra and prelabor vital signs are seen in the fourth stage of labor.

A nurse notes fetal heart rate decelerations that appear to start just prior to a uterine contraction with the fetal heart rate returning to normal by the end of the contraction. How does the nurse document this finding? A. Early deceleration B. Late deceleration C. Mild deceleration D. Variable deceleration

A. Early deceleration An early deceleration looks like the mirror image of a uterine contraction on the fetal heart monitor. The onset of the deceleration begins near the onset of the contraction, the lowest part of the deceleration occurs at the peak of contraction, and the fetal heart rate returns to baseline by the end of the contraction. Early decelerations are usually benign and well tolerated by the fetus. Late decelerations have a late onset and do not resolve until after the contraction has ended. "Mild" is not a term used to describe decelerations. Variable decelerations are inconsistent in their onset, peak, and duration.

The perinatal nurse knows that changes in the pelvic floor musculature that normally occur in labor include which of the following? (Select all that apply.) A. Eversion of the anus B. Exposure of the internal rectal wall C. Pulling downward on the levator ani muscles D. Rectum drawn upward and backward E. Thinning of the perineal body

A. Eversion of the anus B. Exposure of the internal rectal wall E. Thinning of the perineal body Uterine contractions bring about changes in the pelvic floor musculature. The forces of labor cause the levator ani muscles and fascia of the pelvic floor to draw the rectum and vagina upward and forward. During descent, the fetal head exerts increasing pressure and causes thinning of the perineal body from 5 cm to less than 1 cm in thickness. Continued pressure causes the maternal anus to evert, and the interior rectal wall is exposed as the fetal head descends forward.

The perinatal nurse obtains valuable information from a vaginal examination. Which of the following assessments from this examination should the nurse document? (Select all that apply.) A. Extent of cervical dilation B. Fetal presentation C. Presence of cervical effacement D. Status of the amniotic membranes E. Strength of uterine contractions

A. Extent of cervical dilation B. Fetal presentation C. Presence of cervical effacement D. Status of the amniotic membranes The vaginal examination provides important information regarding the diameter of the opening of the cervix, which ranges from 1 cm (not dilated) to 10 cm (fully dilated); the status of the amniotic membranes (ruptured or intact); and the fetal presentation and the station or the extent of the fetal descent through the maternal pelvis. A trained examiner can also assess effacement of the cervix during a vaginal exam.

A nurse is caring for a woman in labor whose fetal heart rate tracings show late decelerations. What observation by the nurse indicates that an important outcome for the nursing diagnosis of impaired fetal gas exchange has been met? A. Fetal heart monitor shows accelerations to contractions. B. Fetal heart monitor shows variable decelerations. C. Fetal heart rate rises to180 beats/minute. D. Maternal heart rate returns to baseline between contractions.

A. Fetal heart monitor shows accelerations to contractions. Accelerations in response to contractions are generally considered a sign of fetal well-being, and this variability is an important predictor of adequate fetal oxygenation. If nursing actions for late decelerations have been effective, the nurse should note encouraging fetal signs. The other options do not indicate encouraging fetal signs, nor do they indicate that impaired fetal gas exchange has been resolved.

The perinatal nurse knows that a cephalic presentation has which of the following advantages to the woman in labor? (Select all that apply.) A. Fetal skull bones have the ability to mold during birth. B. The largest part of the fetus is presenting first. C. The presenting part may not totally cover the cervix. D. The shape of the fetal head is optimal for cervical dilatation. E. The top of the fetal head assists with cervical effacement.

A. Fetal skull bones have the ability to mold during birth. B. The largest part of the fetus is presenting first. D. The shape of the fetal head is optimal for cervical dilatation. The following advantages are associated with a cephalic presentation: the fetal head is usually the largest part of the infant and after the fetal head is born, the rest of the body usually delivers without complications; the fetal head is capable of molding and there is sufficient time during labor and descent for molding of the fetal head to occur; molding helps the fetus to maneuver through the maternal birth passage; and the fetal head is smooth and round, which is the optimal shape to apply pressure to the cervix and to aid in dilation. Breech or malpresentations can lead to umbilical cord prolapse because the presenting part (e.g., a foot) may not totally cover the cervix. The presenting part does not influence effacement.

The nurse assesses a woman in labor and finds that her cervix is dilated to 9 cm. The nurse documents the woman to be in what phase of labor? A. First stage B. Second stage C. Third stage D. Fourth stage

A. First stage The first stage of labor begins with regular uterine contractions and ends when the cervix is fully dilated (10 cm). The second stage of labor begins with full dilation of the cervix and ends with the birth of the baby. The third stage of labor is the period of time from the birth of the baby to the complete delivery of the placenta. The fourth stage of labor is the period of maternal physiological adjustment that occurs from the time of delivery of the placenta through the first 1 to 2 hours after birth.

When calling the primary health-care provider regarding a woman's admission, the perinatal nurse includes which of the following information? (Select all that apply.) A. Gestational age and estimated date of birth B. Maternal and fetal vital signs C. Presence of support person(s) D. Status of other children E. Status of the fetal membranes

A. Gestational age and estimated date of birth B. Maternal and fetal vital signs E. Status of the fetal membranes Critical information to relay to the physician or nurse-midwife includes the patient's name and age; gravidity and parity; gestational age and estimated date of delivery; labor status, pattern of contractions, cervical dilatation and effacement; fetal presentation and station; status of the fetal membranes; fetal heart rate and response to contractions; patient's vital signs, especially blood pressure and temperature; any identified risk to maternal or fetal well-being; and the patient's coping ability in response to labor. Presence of support persons and status of other children would not be critical information at this point.

A nurse notes variable decelerations on the fetal heart monitor and is explaining them to the laboring woman and her partner. What information about these patterns does the nurse share? (Select all that apply.) A. Last at least 15 seconds B. Least common type of deceleration pattern C. May be a result of cord compression D. Occur at any time during a contraction E. Return to baseline within 4 minutes

A. Last at least 15 seconds C. May be a result of cord compression D. Occur at any time during a contraction Variable decelerations are inconsistent in the onset, peak, duration, and intensity. They are the most common type of deceleration pattern seen in labor. They last at least 15 seconds, occur any time during a contraction, and may be the result of cord compression. They return to baseline within 2 minutes.

A woman is admitted in labor. The perinatal nurse would demonstrate cultural sensitivity by assessing the patient for which of the following? (Select all that apply.) A. Need for an interpreter B. Pain management and coping techniques C. Preference for food during labor D. Preferences for touch during labor E. Support person during labor

A. Need for an interpreter B. Pain management and coping techniques C. Preference for food during labor D. Preferences for touch during labor E. Support person during labor Culturally oriented views of childbirth help to shape the woman's expectations and ongoing perceptions of the birth experience. The nurse's understanding of the cultural values and expectations attached to childbirth provide a meaningful framework on which to plan and deliver sensitive, appropriate care. Cultural considerations for the laboring woman encompass many elements of the birth experience, including choice of a birth support person, strategies for coping with contractions, pain expression and relief, language preference, use of touch, and food preferences.

A new nurse is preparing to assess the fetal heart rate response to stimulation with vibroacoustic stimulation. What action by the new nurse would prompt the precepting nurse to intervene? A. Nurse attempts stimulation in the presence of fetal bradycardia. B. Nurse attempts stimulation in the presence of ruptured membranes. C. Nurse places stimulation device over the fetal head for 1 to 2 seconds. D. Nurse waits until fetal heart rate is at baseline before initiating the stimulation.

A. Nurse attempts stimulation in the presence of fetal bradycardia. Fetal stimulation should occur when the fetal heart rate is at baseline, and not in the presence of decelerations or bradycardia. If the nurse attempts to stimulate the fetal heart rate in a bradycardic fetus, the preceptor should intervene. The other options are correct steps in the procedure (stimulation can occur in the presence or absence of ruptured membranes).

A nursing instructor explains to the class of nursing students that the critical factors affecting the progress of labor include which of the following? (Select all that apply.) A. Passageway B. Passageway + Passenger C. Passenger D. Productivity E. Psychosocial factors

A. Passageway B. Passageway + Passenger C. Passenger E. Psychosocial factors The 5 P's of labor are Powers, Passageway, Passenger, Passageway + Passenger, and Psychosocial influences. Productivity is not included.

What nursing action best helps to prevent perineal lacerations during birth? A. Providing adequate coaching on pushing and breathing B. Applying warm compresses to the perineum C. Helping the woman to squat during labor D. Performing an episiotomy early in labor

A. Providing adequate coaching on pushing and breathing Adequate coaching on pushing and breathing helps the woman deliver the fetal head in a controlled manner, which reduces the likelihood and/or severity of perineal lacerations. Applying warm compresses to the perineum is one of many complementary therapies used to reduce birth trauma. However, results have been inconsistent.

The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the 4 Ps that interact during childbirth. select all a. powers b. passage c. position d. passenger e. psyche

A. powers, B. passage, D. passenger, E. psyche

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 a. progesterone levels become higher than estrogen levels b. natural oxytocin in conjunction with other substances plays a role c. stretching, pressure, and irritation of the uterus and cervix increase d. the secretion of prostaglandins from the fetal membranes decreases

B, C. rationale: Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labor's initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

A woman who is 37 weeks pregnant calls the birthing center to report a gush of clear fluid from her vagina. What response by the nurse is best? A. "Are you having any pain?" B. "Come in now to be evaluated." C. "Did you have any trauma?" D. "It is too early for membrane rupture."

B. "Come in now to be evaluated." Any gush of fluid from a pregnant woman's vagina needs to be evaluated, even if there are no contractions. The other responses are not appropriate for this situation.

A woman who is 40 weeks pregnant calls the clinic to report that she noted a small amount of blood-tinged mucus on her toilet tissue this morning. What response by the nurse is most appropriate? A. "Come to the clinic today for an examination." B. "Labor will probably start within 48 hours." C. "Lie on your left side and count fetal kicks." D. "Stay on bedrest until your labor begins."

B. "Labor will probably start within 48 hours." During pregnancy, the cervix is plugged with mucus. When effacement begins, small capillaries can rupture, leading to an expulsion of the blood-tinged mucus plug, called bloody show. Its presence often indicates that labor will begin in 24 to 48 hours. No action is needed at this time.

A nurse assessing a fetal heart monitor notes minimal baseline variability not associated with a fetal sleep cycle. There is no change after fetal scalp stimulation. What action by the nurse is most important? A. Administer a bolus of IV fluids. B. Administer oxygen at 8-10 L/min per mask. C. Offer support to the patient and her partner. D. Prepare to assist with internal fetal monitoring.

B. Administer oxygen at 8-10 L/min per mask. All options are correct actions for the nurse to take in this situation. However, actions should be prioritized using the A (airway), B (breathing), C (circulation) method. The breathing action (administering oxygen) should occur prior to the circulation action (IV fluids) in the absence of any other data.

A woman and her partner are interested in exploring different birthing options. What action by the perinatal nurse would be most helpful? A. Advise the couple to ask for referrals from friends. B. Arrange tours of different birthing facilities. C. Give the couple brochures from different facilities. D. Refer to social work for an insurance review.

B. Arrange tours of different birthing facilities. Although all options may be beneficial, the best way to help a couple explore birthing options is to encourage them to tour various facilities to gain an understanding of what to expect from the experience. Touring birthing units is often included in childbirth education.

A nurse assesses fetal heart tones at 100 beats/minute. Which action by the nurse takes priority? A. Administer 100% oxygen. B. Assess the maternal heart rate. C. Notify the primary care provider. D. Turn the woman on her left side.

B. Assess the maternal heart rate. Causes of fetal bradycardia include late fetal hypoxia, medications (beta blockers), maternal hypotension, prolonged umbilical cord/fetal head compression, fetal bradyarrhythmias, uterine hyperstimulation, abruptio placentae, uterine rupture or vasa previa, or vagal stimulation during the second stage of labor. However, it is also possible that the maternal heart tones are mistakenly counted as fetal heart tones. The first action by the nurse is to assess the maternal heart rate to confirm that it is not being counted as the fetal heart rate. This is done whether the nurse is using a fetoscope or external fetal monitoring.

A woman in labor seems to be progressing more slowly than expected. Which action should the nurse perform first? A. Administer oxygen by face mask. B. Assess the woman for a full bladder. C. Increase the rate of the IV fluids. D. Provide stimulants such as coffee.

B. Assess the woman for a full bladder. A full bladder can hinder the progression of labor by slowing the descent of the fetus. A full bladder can also contribute to increased pain during contractions. The nurse should assess the woman for a full bladder. This is easy and quick to accomplish. The woman should be encouraged to void every 2 hours. The other options are not warranted.

A woman in the perinatal clinic reports a gush of vaginal fluid after sneezing. The nurse performs a Nitrazine tape test and documents that the tape is beige in color. What action should the nurse take? A. Ask the woman about recent sexual intercourse. B. Assess the woman for urinary incontinence. C. Arrange for the woman to be admitted to the birthing unit. D. Inquire if the woman has symptoms of a vaginal infection.

B. Assess the woman for urinary incontinence. Amniotic fluid is alkaline with a pH between 6.5 and 7.5. When the alkaline amniotic fluid is exposed to Nitrazine tape, the tape turns blue-green, gray, or deep blue. Urine and vaginal secretions are usually acidic. Because the gush of fluid occurred after sneezing, the nurse should assess the woman for urinary incontinence (especially stress incontinence). The presence of semen or certain bacterial infections can also lead to an alkaline result. The woman does not need admission.

A young girl in active labor arrives at the hospital without having had any prenatal care. She is extremely anxious and crying out in pain. What would the nurse assess to best determine that goals for the diagnosis of knowledge deficit have been met? (Select all that apply.) A. Begs her mother to stay with her while giving birth B. Can describe expected labor progress and states she is in less pain C. Is able to cooperate with breathing instructions during contractions D. Is able to give a history of this pregnancy to the admitting nurse E. States that after this birth, she wants to learn about birth control

B. Can describe expected labor progress and states she is in less pain C. Is able to cooperate with breathing instructions during contractions A lack of knowledge can lead to anxiety and increased perceived pain. When the patient understands labor progression and the events surrounding childbirth, she will be better able to cooperate with breathing instructions and hopefully will feel less pain as she feels more in control. The other actions do not show the benefit of an educated patient.

A nurse assessing fetal heart tones hears them best below the level of the maternal umbilicus. What type of fetal presentation would this nurse expect? A. Breech B. Cephalic C. Footling D. Shoulder

B. Cephalic Typically with a cephalic presentation, fetal heart tones will be heard best below the level of the maternal umbilicus.

A woman is in the early latent phase of labor and is frustrated by the length of time this stage is taking. What action by the nurse is best? A. Administer 100% oxygen by face mask. B. Encourage frequent position changes or walking. C. Have the woman rest between contractions. D. Place the woman in a left side-lying position.

B. Encourage frequent position changes or walking. Frequent position changes and walking are beneficial in helping to promote the descent of the fetus during labor. The nurse should encourage the woman to try several positions (squatting, leaning over a piece of furniture, hands and knees position) and walking to try to enhance the progression of her labor. The other actions are not warranted.

The perinatal nurse describes prelabor or Braxton Hicks contractions to the prenatal class attendants as which of the following? (Select all that apply.) A. Contributing to cervical effacement and dilation B. Felt in the abdomen or groin C. Intensely painful D. Irregular E. Regular and progressive

B. Felt in the abdomen or groin D. Irregular As the pregnancy approaches term, most women become more aware of irregular contractions called Braxton Hicks contractions. As the contractions increase in frequency (they may occur as often as every 10 to 20 minutes), they may be associated with increased discomfort. Braxton Hicks contractions are usually felt in the abdomen or groin region, and patients may mistake them for true labor. It is believed that these contractions contribute to the preparation of the cervix and uterus for the advent of true labor. However, Braxton Hicks contractions do not lead to dilation or effacement of the cervix, and therefore are often termed "false labor."

A nurse has assessed baseline fetal heart tones (FHTs) by auscultation and documents a funic soufflé of 158 beats/minute and a uterine soufflé of 90 beats/minute. When the first nurse gives a handoff report to an oncoming nurse, what can the second nurse conclude from this information? A. Fetal and maternal heart rates are outside of normal limits. B. Fetal and maternal heart rates are within normal limits. C. The second nurse cannot distinguish between fetal and maternal heart rates. D. There is a great deal of fetal heart rate variability between contractions.

B. Fetal and maternal heart rates are within normal limits. Fetal heart tones (funic soufflé) should be in the range of 110 to 160 beats/minute, so FHTs are within normal limits. The maternal heart rate (uterine soufflé) is also within normal limits.

The perinatal nurse describes normal maternal signs and symptoms associated with lightening to the prenatal class attendants. These signs and symptoms include which of the following? (Select all that apply.) A. Difficulty breathing B. Increased urinary frequency C. Increased vaginal secretions D. Leg cramps E. Nausea and vomiting

B. Increased urinary frequency C. Increased vaginal secretions D. Leg cramps The downward settling that occurs during lightening may also lead to the following maternal symptoms: leg cramps or pains, increased pelvic pressure, increased urinary frequency, increased venous stasis that may cause edema in the lower extremities, and increased vaginal secretions related to congestion in the vaginal mucosa. The downward movement of the fetus actually may make breathing easier. Nausea and vomiting are not associated symptoms.

A woman's birthing plan includes completing the latent phase of the first stage of labor at home. When should the nurse teach the woman to come in to the birthing unit? A. After 10 hours of mild contractions B. When contractions are 3 to 5 minutes apart C. When contractions are experienced in the back D. When strong contractions occur 2 to 3 minutes apart

B. When contractions are 3 to 5 minutes apart The latent phase of labor is often completed at home and includes contractions that feel like menstrual cramping accompanied by low back pain. During this phase, contractions are typically 5 minutes apart, last 30 to 45 seconds, and are considered mild. This phase of labor can last up to 14 hours. However, it is not the length of time in the phase but rather the characteristics of the contractions that would signal to the woman that she is entering the active phase of labor. Strong contractions that occur 2 to 3 minutes apart indicate the transition phase of labor.

During the second stage of labor, a nurse encourages effective pushing by the woman. What directions from the nurse best achieve this? A. "Hold your breath and push as hard as you can." B. "Now that you are fully dilated, start pushing." C. "Push when you feel the urge and breathe between attempts." D. "When you feel a contraction, push with your mouth closed."

C. "Push when you feel the urge and breathe between attempts." Open-glottis pushing is the recommended technique of pushing during contractions. When the woman feels the urge to push, she is instructed to bear down while continuing to breathe between contractions. She is encouraged to only hold her breath for 5 to 6 seconds at a time so that air escapes during the pushing. This process facilitates maternal-fetal circulation and gradual fetal descent. The other instructions are not consistent with this method.

A husband in the labor suite is concerned that as his wife's labor progresses, she has become distant, is not interested in conversation, and, at times, is short with him. Which response by the nurse is best? A. "Don't worry; women often get this way during labor." B. "Maybe if you step out for a while, she'll feel better." C. "She must concentrate to cope with her labor." D. "This is a difficult period; it will be over shortly."

C. "She must concentrate to cope with her labor." During the active phase of labor, many women tend to draw inward in an attempt to cope with the increasing demands of the labor. The nurse should reassure the husband that this is a normal response. The first option does not give the husband any useful information. The woman needs her support person with her and the husband should not be sent away. The last option is dismissive.

A nulliparous woman in labor is 3 cm dilated at 10:00 a.m. Based on knowledge of the average nulliparous woman's progression, when would the nurse expect her to be fully dilated? A. 12:00 p.m. B. 2:00 p.m. C. 5:00 p.m. D. 10:00 p.m.

C. 5:00 p.m. A nulliparous woman, on average, dilates 1 cm/hour of labor. The nurse would expect this woman to be fully dilated 7 hours from the initial assessment, or at 5:00 p.m.

The OB nurse assesses moderate baseline variability on the fetal heart monitor. What action by the nurse is best? A. Administer a bolus of IV fluids. B. Discontinue oxytocin, if it is being delivered. C. Document the findings in the woman's chart. D. Perform fetal scalp or vibroacoustic stimulation.

C. Document the findings in the woman's chart. Baseline variability is the most important predictor of adequate fetal oxygenation during labor. It can be described as absent, minimal, moderate, or marked. Adequate variability is described as moderate. This is a normal and reassuring finding and should be documented in the patient's chart. No further action is needed.

The perinatal nurse knows that when the fetal head is fully extended and the occiput is near the spine, the delivery team should prepare for the presenting fetal part to be which of the following? A. Brow B. Chin C. Face D. Sacrum

C. Face In the face presentation, the fetal head is fully extended and the occiput is near the fetal spine. The submentobregmatic diameter presents to the maternal pelvis; the face is the presenting part.

The perinatal nurse describes different breech positions to the student nurse. The fetal position with extended legs toward the fetal shoulders is best described as which of the following? A. Complete breech B. Footling breech C. Frank breech D. Incomplete breech

C. Frank breech There are three types of breech presentations: frank, complete, and footling. The frank breech is the most common of all breech presentations. In this position, the fetal legs are completely extended up toward the fetal shoulders. The hips are flexed, the knees are extended, and the fetal buttocks present first in the maternal pelvis. The complete, or full, breech position is the same as the frank breech position, except the knees are flexed and the legs crossed, with the fetal buttocks presenting first. In the footling breech position, one or both of the fetal leg(s) are extended, with one foot ("single footling") or both feet ("double footling") presenting first into the maternal pelvis.

A new nurse is caring for a woman in the transition phase of labor. The nurse attempts to engage the woman in conversation and chats even when the woman doesn't respond to these attempts. What action by the nurse's preceptor is most appropriate? A. Direct the nurse to attempt conversation with the support person. B. Encourage the nurse to keep attempting to engage the woman in conversation. C. Gently ask the nurse to refrain from unnecessary conversation. D. Tell the nurse not to take the woman's silence as a personal rejection.

C. Gently ask the nurse to refrain from unnecessary conversation. During the more intense phases of labor, women may draw inward in an attempt to cope with the increasing demands of their labor. Also, there are cultural differences in the way people respond to silence and conversation. Because this woman appears to be concentrating on her own body and labor and not responding to the nurse, the preceptor should gently ask the new nurse to refrain from all but necessary communication. This shows respect for the work the woman is doing. It is also a good idea to let the new nurse know that this is probably not a personal rejection, but it is more important to respect the woman's need for quiet.

A patient's cervix is 8 cm dilated and she is 100% effaced. What action by the nurse is most important at this time? A. Allow the support person to be at the bedside. B. Encourage the woman to bear down. C. Have the woman avoid pushing at this time. D. Instruct the woman to rest between contractions.

C. Have the woman avoid pushing at this time. Pushing against a partially dilated cervix can lead to cervical edema and damage and can adversely affect the progress of the woman's labor. It is most important to protect the patient from injury. Encouraging rest between contractions and allowing the support person at the bedside are also important, but safety comes first.

A nurse assesses the fetal position in a laboring woman. The fetal position is documented as LSP. What action by the nurse is best? A. Continue to support the woman's labor efforts. B. Document the findings in the woman's chart. C. Inform the provider; prepare for possible cesarean delivery. D. Turn the woman on her left side; reassess in 30 minutes.

C. Inform the provider; prepare for possible cesarean delivery. LSP indicates left, sacrum, posterior. This malpresentation may signal the need for a cesarean delivery. The nurse should not just support the woman's labor efforts, nor should the nurse document without taking other action. Turning the woman on her left side is not warranted.

A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart rate increased during a contraction from 140 to 158. What action by the nurse preceptor is best? A. Gather equipment for internal FHT monitoring. B. Have the nurse document FHT of 140/158. C. Instruct the nurse to assess FHT between contractions. D. Tell the nurse to count only for 30 seconds.

C. Instruct the nurse to assess FHT between contractions. Baseline fetal heart tones can only be assessed during the absence of uterine activity. The preceptor should instruct the new nurse to listen for FHTs between contractions. The woman does not need internal FHT monitoring based on this assessment. The reading is inaccurate, so the nurse preceptor should not have the new nurse document these findings and this method (140/158) is not appropriate. The new nurse may have to count fetal heart tones for only 30 seconds if the woman is having frequent contractions, although assessing for 1 minute is the most accurate method.

A nurse is measuring the frequency of a laboring woman's contractions. How does the nurse accomplish this correctly? A. Counts the number of contractions measured at the same intensity in 1 full minute B. Feels the fundus during the acme of the contraction and notes the fundal firmness C. Measures the beginning of one contraction to the beginning of the next contraction D. Measures the time from the beginning of one contraction to the end of the same contraction

C. Measures the beginning of one contraction to the beginning of the next contraction The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction, not by counting contractions in 1 minute. Feeling the firmness of the fundus during contractions measures intensity. Measuring the time from the start of one contraction to the end of the same contraction measures duration.

The faculty member teaching a class of students explains several theories regarding the onset of labor. Which of the following does the faculty member include? (Select all that apply.) A. Closure of ductus arteriosus B. Molding of the fetal head C. Placental aging D. Pressure on the cervix E. Uterine muscle stretching

C. Placental aging D. Pressure on the cervix E. Uterine muscle stretching Several theories regarding the onset of labor exist and include (among others) placental aging, pressure on the cervix, and uterine muscle stretching.

A nurse reads in a woman's chart that the fetus is in a longitudinal lie. What can the nurse conclude about this situation? A. The fetal head is flexed prior to delivery. B. The fetal head-to-tailbone axis is at a 90° angle to the woman's head-to-tailbone axis. C. The fetal head-to-tailbone axis is the same as the woman's head-to-tailbone axis. D. Vaginal birth will be very difficult.

C. The fetal head-to-tailbone axis is the same as the woman's head-to-tailbone axis. The fetal lie is the relationship of the long axis of the woman to the long axis of the fetus. If the head-to-tailbone axis of the fetus is the same as the woman's, the fetus is in a longitudinal lie. This occurs in more than 99% of pregnancies. Flexion of the fetal head is related to fetal attitude. When the long axis of the fetus is at a 90° angle to the long axis of the woman, it is called a transverse lie; this occurs in fewer than 1% of pregnancies.

A nurse is assessing a woman in labor. In order to assess the fetal position most accurately, which of the following methods should be used? A. Auscultation of fetal heart tones B. Leopold maneuvers C. Ultrasound examination D. Vaginal examination

C. Ultrasound examination Ultrasound is the most accurate way to assess the fetal position. Leopold maneuvers are not always accurate and may be clinically difficult, which also makes assessing fetal heart tones more difficult. A vaginal examination can be used, but if the membranes are still intact or if the cervix is only minimally dilated, the examiner may not be able to determine the fetus's position.

The nurse explains to the class of nursing students that umbilical cord clamping occurs at what time after birth? A. Immediately B. After 15 seconds C. After 30 to 60 seconds D. After 60 to 120 seconds

D. After 60 to 120 seconds For the term infant, cord clamping should be delayed for 60 to 120 seconds (or until cord pulsation ceases). This provides the infant with more blood volume, red blood cells, and hematopoietic cells than when the cord is clamped immediately. The oxygen-rich blood traveling through the cord allows the neonate additional time to adjust to the outside world and a new way of breathing.

A nurse notes a perineal laceration that extends into the rectal mucosa after a woman gives birth to a full-term baby. How does the nurse document this information? A. First-degree laceration B. Second-degree laceration C. Third-degree laceration D. Fourth-degree laceration

D. Fourth-degree laceration A fourth-degree laceration extends into the rectal mucosa and exposes the lumen of the rectum. A first-degree laceration involves only the perineal skin and vaginal mucosa. A second-degree laceration involves the skin, mucous membrane, and fascia of the perineal body. A third-degree laceration involves the skin, mucous membrane, and muscle of the perineal body and extends into the rectal sphincter.

At 9:00 a.m., the OB nurse assesses fetal station at 0. The laboring woman has strong, regular contractions. At 10:30 a.m., the nurse again assesses fetal station at 0. What action by the nurse is best? A. Document the findings and continue to assess frequently. B. Encourage the woman to bear down during contractions. C. Increase the woman's IV fluid rate and reassess in 30 minutes. D. Inform the provider and prepare for possible cesarean delivery.

D. Inform the provider and prepare for possible cesarean delivery. As labor advances and the presenting fetal part descends, the station should progress to a numerically higher positive station (numerically higher positive number). If the station does not change in the presence of strong, regular contractions, this may indicate a problem with the relationship between the maternal pelvis and the fetus (cephalopelvic disproportion). The nurse should inform the provider and prepare for a possible cesarean delivery. Documentation should occur in all situations, but more action is needed. Increasing the IV fluid rate is not warranted. The woman should be encouraged to bear down only after the cervix is totally dilated.

A nurse assessing a woman in labor notes late decelerations on the fetal monitor and documents contractions occurring every 1 to 2 minutes. Oxytocin (Pitocin) is being infused IV, and oxygen is being delivered at 8 L/min per mask. The woman is positioned on her left side. What action by the nurse takes priority? A. Discontinue the oxygen. B. Increase the oxytocin rate. C. Assist the woman to a supine position. D. Stop the oxytocin infusion.

D. Stop the oxytocin infusion. Late decelerations are a sign of uteroplacental insufficiency and are often indicative of hypoxia and metabolic acidemia. Contractions that occur this frequently signify uterine hyperstimulation. Both circumstances indicate that the oxytocin should be stopped immediately. Discontinuing the oxygen and increasing the oxytocin infusion are both contraindicated. Placing the woman in a supine position can lead to maternal hypotension, worsening this situation.

A nurse suspects that a laboring woman has entered the second stage of labor by what assessment? A. Cervix is more than 50% dilated. B. Contractions are more frequent. C. Contractions are more intense. D. Woman has a strong urge to push.

D. Woman has a strong urge to push. The second stage of labor commences when the cervix is fully dilated and ends with the birth of the baby. The nurse (or woman) often suspects this has occurred when the woman has strong urges to push or has involuntary bearing-down efforts. Contractions remain similar to those experienced during transition.

A client asks the nurse how she can tell if labor is real. What should the nurse give as an explanation. select all. a. in true labor, the cervix begins to dilate b. in true labor, the contractions are felt in the abdomen and groin c. in true labor, contractions often resemble menstrual cramps during early labor d. in true labor, contractions are consistent in frequency, duration, and intensity in the early stages e. in true labor, your contractions tend to increase in frequency, duration, and intensity with walking.

a, c, e

Which maternal factor may inhibit fetal descent during labor? a. A full bladder b. Decreased peristalsis c. Rupture of membranes d. Reduction in internal uterine size

a. A full bladder

Which clinical finding 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. A gush of blood appears. b. The uterus rises upward in the abdomen. d. The cord descends further from the vagina.

A 28-year-old gravida 1, para 0 patient 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; however, it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. Which questions should the nurse pose to the patient during this telephone triage? (Select all that apply.) a. Does she think that her membranes have ruptured? b. Is there any evidence of bloody show? c. Instruct the patient to keep monitoring her contraction pattern and call you back if they become more regular. d. When is her next scheduled visit with her health care provider? e. Tell her to come into the hospital for evaluation.

a. Does she think that her membranes have ruptured? e. Tell her to come into the hospital for evaluation.

2. A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.) a. In true labor, the cervix begins to dilate. b. In true labor, the contractions are felt in the abdomen and groin. c. In true labor, contractions often resemble menstrual cramps during early labor. d. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages. e. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

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

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

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

After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the most appropriate nursing action at this time? a. Place a warm blanket over the patient. b. Place the baby on the patient's abdomen. c. Tell the patient that chills are expected after birth. d. "What do you mean by your words 'very cold'?"

a. Place a warm blanket over the patient.

he 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.) a. Powers b. Passage c. Position d. Passenger e. Psyche

a. Powers b. Passage d. Passenger e. Psyche

A laboring patient 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? a. The acme b. The interval c. The increment d. The decrement

a. The acme

A patient just delivered her baby via the vaginal route. The patient asks the nurse why the baby's head is not round, but oval. Which explanation should the nurse provide the patient? a. This results from molding. b. This results from lightening. c. This results from the fetal lie. d. This results from the fetal presentation.

a. This results from molding. The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

To determine if the patient is in true labor, the nurse would assess for changes in a. cervical dilation. b. amount of bloody show. c. fetal position and station. d. pattern of uterine contractions.

a. cervical dilation.

An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an indication of a. lightening. b. breech presentation. c. urinary tract infection. d. onset of Braxton-Hicks contractions.

a. lightening. As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

The primary difference between the labor of a nullipara and that of a multipara is a. total duration of labor. b. level of pain experienced. c. amount of cervical dilation. d. sequence of labor mechanisms.

a. total duration of labor.

Which maternal factor may inhibit fetal descent a. a full bladder b. decreased peristalsis c. rupture of membranes d. reduction in internal uterine size

a. a full bladder rationale: a full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part.

A 28 yr 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 mins and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse. select all a. ask her if she thinks that her membranes have ruptured b. ask her if she has any evidence of bloody show c. have her keep monitoring her contraction pattern and call you back if they become more regular d. ask her when she has her next scheduled visit with her HCP e. tell her to come into the hospital for evaluation

a. ask her if she thinks her membranes have ruptured e. tell her to come into the hospital for evaluation

Which clinical findings would be considered to be normal for a preterm fetus during the labor period a. baseline tachycardia b. baseline bradycardia c. fetal anemia d. acidosis

a. baseline tachycardia rationale: because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system

To determine if the client is in true labor, the nurse would assess for changes in a. cervical dilation b. amount of bloody show c. fetal position and station d. pattern of uterine contractions.

a. cervical dilation

An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates a. Lightening b. breech presentation c. urinary tract infection d. onset of braxton hicks contractions

a. lightening rationale: as the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps

After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the best nursing action is response to this statement a. place a warm blanket over the patient b. place the baby on the patients abdomen c. tell the patient that chills are expected after birth d. what do you mean by your words "very cold"

a. place a warm blanket over the patient rationale: many women are chilled after birth.

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 a. the acme b. the interval c. the increment d. the decrement

a. the acme rationale: the acme is the peak or period of greatest strength during the middle of a contraction cycle.

A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client a. This results from molding b. this results from lightening c. this results from the fetal lie d. this results from the fetal presentation

a. this results from molding rationale: the sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis.

The primary difference between labor of a nullipara and that of a multipara is a. total duration of labor b. level of pain experienced c. amount of cervical dilation d. sequence of labor mechanisms

a. total duration of labor rationale: multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter.

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? a. "You will need to remain in bed attached to the electronic fetal monitor." b. "Breathe with me slowly, in through your nose and out through your mouth." c. "I will begin the administration of 1000 mL of IV fluid so you can have an epidural." d. "Your partner will need to change into scrub attire to attend the imminent birth."

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

The primiparous patient at 39 weeks' gestation states to the nurse, "I can breathe easier now." What is the nurse's most appropriate response? a. "Your labor will start any day now since the baby has dropped." b. "That process is called lightening. Do you have to urinate more frequently?" c. "Contact your health care provider when your contractions are every 5 minutes for 1 hour." d. "You will likely not feel you baby's movements as much now, so do not be concerned."

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

Which physiologic event is the key indicator of the commencement of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes

b. Cervical dilation and effacement The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Extension b. Engagement c. Internal rotation d. External rotation

b. Engagement Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

A laboring patient states to the nurse, "I have to push!" What is the next nursing action? a. Contact the health care provider. b. Examine the patient's cervix for dilation. c. Review with her how to bear down with contractions. d. Ask her partner to support her head with each push.

b. Examine the patient's cervix for dilation.

Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Station b. Flexion c. Descent d. Engagement

b. Flexion The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet.

The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.) a. Progesterone levels become higher than estrogen levels. b. Natural oxytocin in conjunction with other substances plays a role. c. Stretching, pressure, and irritation of the uterus and cervix increase. d. The secretion of prostaglandins from the fetal membranes decreases.

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

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? a. Perform a vaginal exam to denote progress. b. Notify the health care provider. c. Initiate parenteral therapy. d. Apply oxygen via nasal cannula at 8 L/minute.

b. Notify the health care provider.

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? a. On her back b. On her left side c. On her right side d. On her hands and knees

b. On her left side

The nurse is assessing a patient in the active phase of labor. What should the nurse expect during this phase? a. The patient is sociable and excited. b. The patient is requesting pain medication. c. The patient begins to experience the urge to push. d. The patient experiences loss of control and irritability.

b. The patient is requesting pain medication. During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage

b. Actice Phase The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

A client whose cervix is dilated to 5 cm is considered to be in which phase of labor. a. latent phase b. active phase c. second stage d. third stage

b. active phase rationale: the active phase is dilation 4 to 7 cm latent phase is true labor to 3cm second stage begins with full dilation of cervix third stage is birth of baby to expulsion of placenta

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 the he's doing now, he could tell her when the contractions are a. 2 mins apart b. at their scene c. at their increment d. at their decrement

b. at their scene rationale: when the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused.

The HCP for a laboring patient makes the following entry into the patients record: 3/50%-1. What instruction will the nurse implement with the patient a. You will need to remain in bed attached to the electronic fetal monitor b. breathe with me slowly, in through your nose, out through your mouth c. I will begin the administration of 1000 mL of IV fluid so you can have an epidural d. your partner will need to change into scrub attire to attend the imminent birth

b. breathe with me slowly, in through your nose, out through your mouth. rationale: this client is in the latent phase of the first stage of labor.

Which event is the best indicator of true labor a. bloody show b. cervical dilation and effacement c. fetal descent into the pelvic inlet d. uterine contractions every 7 mins.

b. cervical dilation and effacement rationale: the conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix.

The assessment finding which indicates that the client is in the active phase of the first stage of labor is: a. 80% effacement b. dilation of 5 cm c. presence of bloody show d. regular contraction every 3 to 4 mins

b. dilation of 5 cm rationale: active phase of labor is defined as cervical dilation between 4 to 7 cm

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet a. extension b. engagement c. internal rotation d. external rotation

b. engagement rationale: engagement occurs when the presenting part fully enters the pelvic inlet.

A laboring patient states to the nurse "I have to push". What is the next nursing action a. Contact the HCP b. examine the patients cervix for dilation c. review with her how to bear down with contractions d. ask her partner to support her head with each push

b. examine the patients cervix for dilation rationale: when the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation

Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis a. station b. flexion c. descent d. engagement

b. flexion rationale: the anterior-posterior diameter of the head varies with how much it is flexed.

On admission to the labor and birth unit, a 38 yr 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 a. perform a vaginal exam to denote progress b. notify the HCP c. initiate parenteral therapy d. apply oxygen via nasal cannula at 8 l/min

b. notify HCP rationale: a transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated

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. a. on her back b. on her left side c. on her right side d. on her hands and knees

b. on her left side rationale: LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives 1. by use of gravity, the fetus will most likely stay in the LOA position 2. increase perfusion of the placenta and increase oxygen to the fetus

The primipara at 39 weeks gestation states to the nurse "I can breathe easier now". What is the nurses best response a. your labor will start any day now since the baby has dropped b. That process is called lightening. Do you have to urinate more frequently c. contact your HCP when your contractions are every 5 minutes for 1 hour d. you will likely not feel your babys movements as much now, so do not be concerned

b. that process is called lightening. Do you have to urinate more frequently

The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase a. the client is sociable and excited b. the client is requesting pain medication c. the client begins to experience the urge to push d. the client experiences loss of control and irritability.

b. the client is requesting pain medication rationale: during the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication

The nurse is assessing the duration of a patient's labor contractions. Which method does the nurse implement to assess the duration of labor contractions? a. Assess the strongest intensity of each contraction. b. Assess uterine relaxation between two contractions. c. Assess from the beginning to the end of each contraction. d. Assess from the beginning of one contraction to the beginning of the next.

c. Assess from the beginning to the end of each contraction. Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

Which assessment finding indicates that cervical dilation and/or effacement has occurred? a. Onset of irregular contractions b. Cephalic presentation at 0 station c. Bloody mucus drainage from vagina d. Fetal heart tones (FHTs) present in the lower right quadrant

c. Bloody mucus drainage from vagina

1. The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction? a. Little to no affect b. Increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Continues except when placental functions are reduced

c. Diminishes as the spiral arteries are compressed During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

Pregnant patients can usually tolerate the normal blood loss associated with childbirth because of which physiologic adaptation to pregnancy? a. A higher hematocrit b. Increased leukocytes c. Increased blood volume d. A lower fibrinogen level

c. Increased blood volume Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

Which assessment finding would cause a concern for a patient who had delivered vaginally? a. Estimated blood loss (EBL) of 500 mL during the birth process b. White blood cell count of 28,000 mm3 postbirth c. Patient complains of fingers tingling d. Patient complains of thirst

c. Patient complains of fingers tingling

The nurse assesses a laboring patient's contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 seconds, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern? a. Stage 1, latent phase b. Stage 2, latent phase c. Stage 1, active phase d. Stage 2, active phase

c. Stage 1, active phase

If a notation on the patient's health record states that the fetal position is LSP, this indicates that the a. head is in the right posterior quadrant of the pelvis. b. head is in the left anterior quadrant of the pelvis. c. buttocks are in the left posterior quadrant of the pelvis. d. buttocks are in the right upper quadrant of the abdomen.

c. buttocks are in the left posterior quadrant of the pelvis.

The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions a. Assess the strongest intensity of each contraction b. assess uterine relaxation between two contractions c. assess from the beginning to the end of each contraction d. assess from the beginning of one contraction to the beginning of the next

c. assess from the beginning to the end of each contraction rationale: duration of labor contractions is the average length of contractions from beginning to end.

An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is a. onset of irregular contractions b. cephalic presentation at 0 station c. bloody mucus drainage from the vagina d. fetal heart tones (FHTs) present in the lower right quadrant

c. bloody mucus drainage from the vagina rationale: cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix

If a notation on the clients health record states that the fetal position is LSP, this means that the a. head is in the right posterior quadrant of the pelvis b. head is in the left anterior quadrant of the pelvis c. buttocks are in the left posterior quadrant of the pelvis d. buttocks are in the right upper quadrant of the abdomen

c. buttocks are in the left posterior quadrant of the pelvis rationale: LSP explains the position of the fetus in the maternal pelvis. L = left side of pelvis, S= sacrum (fetus in breech presentation), P = posterior quadrants of the pelvis

Which assessment finding would cause a concern for a client who had delivered vaginally a. estimated blood loss (EBL) of 500mL during the birth process b. white blood cell count of 28,000 postbirth c. client complains of fingers tingling d. client complains of thirst

c. client complains of fingers tingling rationale: a clients complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor.

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 a. Is not significantly affected b. increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Continues except when placental functions are reduced

c. diminishes as the spiral arteries are compressed rationale: during labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle.

Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have a. a higher hematocrit b. increased leukocytes c. increased blood volume d. a lower fibrinogen level

c. increased blood volume rationale: women have a significant increase in blood volume during pregnancy.

The nurse assess a laboring patients contraction pattern and notes the frequency at every 3 to 4 mins, duration 50 to 60 seconds, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern a. stage 1, latent phase b. stage 2, latent phase c. stage 1, active phase d. stage 2, active phase

c. stage 1, active phase rationale: in the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds, and an intensity that ranges from moderate to strong.

The nurse is directing an unlicensed assistive personnel (UAP) to obtain maternal vital signs between contractions. Which statement is the appropriate rationale for assessing maternal vital signs between contractions rather than at another interval? a. Vital signs taken during contractions are inaccurate. b. During a contraction, assessing fetal heart rate is the priority. c. Maternal blood flow to the heart is reduced during contractions. d. Maternal circulating blood volume increases temporarily during contractions.

d. Maternal circulating blood volume increases temporarily during contractions. During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

5. The laboring patient asks the nurse how the labor contractions cause the cervix to dilate. The nurse responds that labor contractions facilitate cervical dilation by a. promoting blood flow to the cervix. b. contracting the lower uterine segment. c. enlarging the internal size of the uterus. d. pulling the cervix over the fetus and amniotic sac.

d. pulling the cervix over the fetus and amniotic sac. Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down. PTS: 1 DIF: Cognitive Level: Application REF: 198

Uncontrolled maternal hyperventilation during labor results in a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis. Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with a. more rapid labor. b. a high risk of infection. c. maternal perineal trauma. d. umbilical cord compression.

d. umbilical cord compression.

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 a. 50 mins b. hours c. 6 to 7 hours d. 8 to 10 hours

d. 8 to 10 hours rationale: the active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 mins. The transition phase lasts hours.

The nurse is directing an UAP to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions a. Vital signs taken during contractions are not accurate b. During a contraction, assessing fetal heart rate is the priority c. Maternal blood flow to the heart is reduced during contractions d. maternal circulating blood volume increases temporarily during contractions

d. maternal circulating blood volume increases temporarily during contractions rationale: during uterine contraction, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume.

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 a. promoting blood flow to the cervix b. contracting the lower uterine segment c. enlarging the internal size of the uterus d. pulling the cervix over the fetus and amniotic sac

d. pulling the cervix over the fetus and amniotic sac rationale: effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward.

uncontrolled maternal hyperventilation during labor results in a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

d. respiratory alkalosis rationale: rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting is respiratory alkalosis.

A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with a. more rapid labor b. a high risk of infection c. maternal perineal trauma d. umbilical cord compression

d. umbilical cord compression rationale: the umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis.