Chapter 13: Labor and Birth Process
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
Ask the woman to describe why she believes that she is in labor.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?
Radiates from the back to the front
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?
The client reports back pain, and the cervix is effacing and dilating.
Which client outcome during active and transitional labor is best?
The client will practice breathing techniques during contractions.
Which statement made by the client in the early phase of labor requires clarification?
"I have been at 3 cm for hours and I am making no progress."
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?
"She is in active labor; she is progressing at this point and we will keep you posted."
A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate?
"You need the cervix to thin so it can stretch more easily."
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?
+4
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?
-2
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?
Braxton Hicks contractions usually decrease in intensity with walking.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?
Complete cervical dilation (dilatation) and time of fetal birth
The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best?
Continue to monitor the progress of labor.
Which cardinal movement of delivery is the nurse correct to document by station?
Descent
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?
Fetal heart rate in relation to contractions
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
Fetal lie
Which is the most important nursing assessment of the mother during the fourth stage of labor?
Hemorrhage
A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?
Long axis of fetus is perpendicular to that of client.
The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?
Longitudinal
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply.
Oxytocin Progesterone Prostaglandins
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?
Push with contractions and rest between them.
A nurse is monitoring a woman in labor. Which assessment finding is most concerning to the nurse?
Temperature is 101.6°F (38.7°C).
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
The client's cervix is fully dilated.
Which description is best when documenting an accurate client contraction?
The client's contractions are 5 minutes apart and last 45 seconds.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?
The frequency of the contractions is every 5 minutes.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?
Third
A pregnant client is being discharged from the labor and birth suite because of false labor. The client asks the nurse how to tell whether the contractions are true contractions or Braxton Hicks contractions. Which description(s) will the nurse mention as characteristic of true contractions? Select all that apply.
begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?
crowning
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?
decrease in circulation and perfusion to the fetus
A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess?
fetal anomalies
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?
head elevated, grasping knees, breathing out
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.
increase in heart rate increase in blood pressure increase in respiratory rate
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?
latent phase
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?
occiput
A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:
occurring about every 5 minutes.
The five "Ps" of labor are
passageway, passenger, position, powers, psych
During the second stage of labor, a woman is generally:
turning inward to concentrate on body sensations.
A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement?
"I feel pressure in my vagina when I have the contraction."
A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate?
Administer the medication piggybacked into a primary IV line using a pump.
A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting?
buttocks
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?
effacement
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?
engagement
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?
increase even if relaxing and taking a shower
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?
increased risk of infection
A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands that which factors are causing the extreme pain in the client? Select all that apply.
lower uterine segment distention stretching and tearing of structures dilation (dilatation) of the cervix
A nurse knows that a doula can be part of a laboring client's health care team. Which intervention would the nurse explain to the client is part of the doula's responsibility?
providing support and explanations during labor and birth
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?
relaxin
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?
restoration of blood flow to uterus and placenta
Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?
rupture of amniotic membranes
A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?
contraction, regular and lasting longer and stronger
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?
ROA
During a prepared childbirth class, the nursing is discussing the differences between true and false labor. Which responses by a client indicate an understanding of false labor? Select all that apply.
"Maintaining hydration by drinking water will lessen false labor pains." "The intensity of contractions is inconsistent in false labor."
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8 to 10
During which time is the nurse correct to document the end of the third stage of labor?
At the time of placental delivery
A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which of the following is an advantage of adopting a kneeling position during labor?
It helps to rotate the fetus in a posterior position.
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?
Nothing. Normal time for stage three is 5 to 30 minutes.
The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor?
Reduce the rate of cesarean births among low-risk women.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?
The fetus is in the true pelvis and engaged.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor?
These contractions help in softening and ripening the cervix.
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?
allowing the woman time to be alone
When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanel (fontanelle). Which description would the nurse include?
approximately 2 to 3 cm in size
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?
dilation (dilatation) of cervix diameter to 10 cm
The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?
second