Course Point Chapter 16
A primigravida who is 40 weeks' pregnant thinks she may be in labor. She calls the nurse and reports that she has had 10 contractions in the last hour. She says that they are mildly painful and last 45 seconds. What is the best response from the nurse ?
"Did your water break? Do you feel the baby moving?" Reference: Chapter 16: Labor and Delivery - Page 295
When collecting data to devise a labor plan for a multiparous woman which question best allows the nurse to develop individualized strategies?
"Tell me how you handled labor pain in your past deliveries." Reference: Chapter 16: Labor and Delivery - Page 311
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process the nurse should point out "0 station" refers to which sign?
"The presenting part is at the true pelvis and is engaged." Reference: Chapter 16: Labor and Delivery - Page 288
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 Reference: Chapter 16: Labor and Delivery - Page 288
The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?
Assess and reposition the woman. Reference: Chapter 16: Labor and Delivery - Page 310
As a woman enters the second stage of labor her membranes spontaneously rupture. When this occurs what would the nurse do next?
Assess fetal heart rate for fetal safety. Reference: Chapter 16: Labor and Delivery - Page 294
The nurse is caring for a client entering the active phase of labor. Which outcome is most appropriate at this time?
Client will adjust body to attain the most comfortable position. Reference: Chapter 16: Labor and Delivery - Page 296
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?
Continue to monitor the client and the fetal heart rate.. Reference: Chapter 16: Labor and Delivery - Page 306
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status Reference: Chapter 16: Labor and Delivery, The Pharmacy 16.1, p. 314.
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department which nursing action is best?
Take no extra measures; prepare for a standard labor. Reference: Chapter 16: Labor and Delivery - Page 286
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. Reference: Chapter 16: Labor and Delivery - Page 288
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?
The mother may have difficulty working effectively with contractions. Reference: Chapter 16: Labor and Delivery, Psyche, p. 291.
Which assessment finding is most important as labor progresses?
The uterus relaxes completely between contractions. Reference: Chapter 16: Labor and Delivery - Page 286
A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line which nursing action is best?
Use distraction therapy. Reference: Chapter 16: Labor and Delivery - Page 318 - 319
Which nursing action has a negative effect on fetal descent?
administering opioid pain medication Reference: Chapter 16: Labor and Delivery - Page 312-313
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?
administration of oxygen by mask Reference: Chapter 16: Labor and Delivery - Page 304
During active labor the nurse observes the client crying during contractions and not using breathing techniques learned during prenatal classes. Which client concern is the priority for the nurse to address at this time?
altered breathing pattern Reference: Chapter 16: Labor and Delivery - Page 297
When applying the ultrasound transducer for continuous external electronic fetal monitoring the nurse would place the transducer at which location on the client's body to record the FHR?
between the umbilicus and the symphysis pubis Reference: Chapter 16: Labor and Delivery - Page 302
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 Reference: Chapter 16: Labor and Delivery - Page 297
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 Reference: Chapter 16: Labor and Delivery, Primary Powers, p. 285.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency which pattern would the nurse anticipate seeing on the monitor?
fetal heart rate declining late with contractions and remaining depressed Reference: Chapter 16: Labor and Delivery - Page 307
A nurse is caring for a client in her fourth stage of labor. Which nursing action(s) is essential during the fourth stage of labor? Select all that apply.
fundal assessment every 15 minutes and assessment of bleeding for expulsion of placental fragments Reference: Chapter 16: Labor and Delivery - Page 300-302
The nurse is caring for a woman who has entered the second stage of labor. Which action by the woman would the nurse correct?
holding breath during pushing Reference: Chapter 16: Labor and Delivery, p. 315.
Place the following stages of labor in order from what occurs first to last. All options must be used.
latent stage-active stage-transition stage-second stage-third stageReference: Chapter 16: Labor and Delivery - Page 294-300
The five "Ps" of labor are:
passageway, passenger, position, powers, psych.Reference: Chapter 16: Labor and Delivery - Page 284-291
The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions?
the interval between the beginning and the end of one contraction Reference: Chapter 16: Labor and Delivery - Page 286
The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions?
the interval between the beginning and the end of one contraction Reference: Chapter 16: Labor and Delivery - Page 286
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.
uterine resting tone-frequency of contractions-intensity of contractions Reference: Chapter 16: Labor and Delivery - Page 302
A primigravida who is 40 weeks' pregnant thinks she may be in labor. She calls the nurse and reports that she has had 10 contractions in the last hour. She says that they are mildly painful and last 45 seconds. What is the best response from the nurse?
"Did your water break? Do you feel the baby moving?" Reference: Chapter 16: Labor and Delivery - Page 295
A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain?
effleurage Reference: Chapter 16: Labor and Delivery - Page 319
A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? Select all that apply.
latent-active-transition Reference: Chapter 16: Labor and Delivery - Page 294
The first stage of labor is often a time of introspection. In light of this which information would guide the nurse's plan of care?
A woman may spend time thinking about what is happening to her. Reference: Chapter 16: Labor and Delivery - Page 294-297
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?
shoulder Reference: Chapter 16: Labor and Delivery - Page 289 - 291
A client comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is in which of the following stages of labor?
second stage Reference: Chapter 16: Labor and Delivery - Page 297-298
Which procedure is contraindicated in an antepartum client with bright red painless bleeding?
Vaginal examination Reference: Chapter 16: Labor and Delivery, Care, p. 296.
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply.
begin irregularly but become regular and predictable-felt first in lower back and sweep around to the abdomen in a wave-increase in duration, frequency, and intensity Reference: Chapter 16: Labor and Delivery - Page 293-295
A primigravida client at 38 weeks' gestation calls the clinic and reports "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." Reference: Chapter 16: Labor and Delivery - Page 294
During an admission assessment of a client in labor the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?
Assess the amount of cervical dilation (dilatation). Reference: Chapter 16: Labor and Delivery - Page 296
During which time is the nurse correct to document the end of the third stage of labor?
At the time of placental delivery Reference: Chapter 16: Labor and Delivery, Third Stage, p. 300.
A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?
Occiput posterior position Reference: Chapter 16: Labor and Delivery - Page 312
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. Reference: Chapter 16: Labor and Delivery - Page 297
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. Reference: Chapter 16: Labor and Delivery - Page 297
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.
Turn the client on her left side-Administer oxygen by mask-Assess client for underlying causes. Reference: Chapter 16: Labor and Delivery - Page 313
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 Reference: Chapter 16: Labor and Delivery - Page 296-297
Which nursing action is required before a client in labor receives an epidural?
giving a fluid bolus of 500 ml Reference: Chapter 16: Labor and Delivery - Page 315
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?
head flexed forward so much that the chin touches the sternum Reference: Chapter 16: Labor and Delivery - Page 288
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side the small parts toward the right side and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant. Reference: Chapter 16: Labor and Delivery - Page 302
Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply.
walking with partner support straddling with forward leaning over a chair-rocking back and forth with foot on chair Reference: Chapter 16: Labor and Delivery - Page 293
Which method does the nurse use to determine fetal presentation position and attitude?
Utilize Leopold maneuvers. Reference: Chapter 16: Labor and Delivery - Page 296
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 Reference: Chapter 16: Labor and Delivery - Page 297
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?
Acceleration of at least 15 bpm for 15 seconds Reference: Chapter 16: Labor and Delivery - Page 306
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out "The baby is coming!"?
Inspect the perineum. Reference: Chapter 16: Labor and Delivery, p. 299
A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Reference: Chapter 16: Labor and Delivery - Page 316
A client has presented in the early phase of labor experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?
Practicing effleurage on the abdomen Reference: Chapter 16: Labor and Delivery - Page 318
A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?
Reassuring; it is associated with normal acid-base balance. Reference: Chapter 16: Labor and Delivery - Page 311
When planning a labor experience for a primigravid understanding which characteristic of labor pain is most helpful?
The characteristics of labor pain follow a pattern. Reference: Chapter 16: Labor and Delivery - Page 312
A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group the nurse determines that the teaching was successful based on which statement by the group?
The pelvic outlet is associated with the true pelvis. Reference: Chapter 16: Labor and Delivery - Page 286
Which procedure is contraindicated in an antepartum client with bright red painless bleeding?
Vaginal examination Reference: Chapter 16: Labor and Delivery - Page 296
A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:
the buttocks are presenting first with both legs extended up toward the face. Reference: Chapter 16: Labor and Delivery - Page 290
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
backache-lightening-bloody show Reference: Chapter 16: Labor and Delivery - Page 293-294
Patterned breathing techniques used in labor provide which benefits? Select all that apply.
conscious relaxation distraction pain relief without special tools Reference: Chapter 16: Labor and Delivery - Page 319
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 Reference: Chapter 16: Labor and Delivery - Page 288
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth?
decreased alertness Reference: Chapter 16: Labor and Delivery - Page 316
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part with the legs extended upward. The nurse identifies this as which type of breech presentation?
frank Reference: Chapter 16: Labor and Delivery - Page 290
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 Reference: Chapter 16: Labor and Delivery - Page 294
During the assessment of a woman in labor the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?
ischial spine Reference: Chapter 16: Labor and Delivery - Page 287-288
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding?
less anxiety Reference: Chapter 16: Labor and Delivery - Page 314
While discussing labor with a client and her partner the nurse is asked what the best position is for giving birth to the baby. The nurse provides them with information that indicates research has shown which position as the best?
position of comfort for the mother Reference: Chapter 16: Labor and Delivery - Page 291
The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?
rupture of membranes Reference: Chapter 16: Labor and Delivery - Page 303
A client comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is in which of the following stages of labor ?
second stage Reference: Chapter 16: Labor and Delivery - Page 297-298
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
-2 station. Reference: Chapter 16: Labor and Delivery - Page 288
A client has just had an epidural placed. Before the procedure her vital signs were as follows: BP 120/70 P90 bmp R18 per min and O2 sat 98%. Now 3 minutes after the procedure the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40 P100 bmp R20 per min and O2 sat 96%. Which interventions should the nurse perform?
Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Reference: Chapter 16: Labor and Delivery - Page 315-316