maternity Chapter 13 -
7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth? A. cesarean B. vaginal C. forceps-assisted D. vacuum extraction
Answer: A Rationale: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.
28. A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor and the passage of the fetus through the birth canal. As part of the class, the nurse explains that specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse identify as being most important in affecting the birth process? Select all that apply. A. Occipitofrontal B. Occipitomental C. Suboccipitobregmatic D. Biparietal E. Diagonal conjugate
Answer: C, D Rationale: The diameter of the fetal skull is an important consideration during the labor and birth process. Fetal skull diameters are measured between the various landmarks of the skull. Diameters include occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal. The two most important diameters that can affect the birth process are the suboccipitobregmatic (approximately 9.5 cm at term) and the biparietal (approximately 9.25 cm at term) diameters. Diagonal conjugate is a measure of the pelvic inlet of the mother.
The nurse is preparing to perform a straight catheterization on a client in labor. What assessment data support this nursing action? a. The fetal head is not descending as expected. b. The urine-specific gravity tests at as higher than expected. c. Trace amounts of protein are found in the urine. d. The fetus is noted to be a breech presentation.
a. The fetal head is not descending as expected. A full bladder puts pressure on the lower uterine segment and prevents the head from descending. In this situation, the health care provider may prescribe a straight catheter (in-and-out catheter) to empty the bladder and allow labor to progress. Trace amounts of protein in the urine is noted with the increased metabolic activity noted with labor, but this finding would not be a reason for urinary catheterization. The client may have concentrated urine, and therefore, an elevated specific gravity, but again, this finding is not a reason to insert a urinary catheter. Breech presentation is uncommon, but if it occurs, it would not necessitate a straight catheterization.
A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? to reduce boggy nature of the uterus to remove pieces left attached to uterine wall to constrict the uterine blood vessels to lessen the chances of conducting an episiotomy
to constrict the uterine blood vessels
When the presenting part of the fetus reaches 0 station ________has occured
Engagement
During the second stage of labor, a woman is generally: a. very aware of activities immediately around her. b. anxious to have people around her. c. no longer in need of a support person. d. turning inward to concentrate on body sensations.
d. turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
In which situation(s) will the nurse anticipate client admission to the labor and delivery unit? Select all that apply. a. The client reports experiencing regular contractions every 5 minutes. b. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation). c. The client reports a burst of energy and starting the completion of the home nursery. d. The health care provider has documented pelvic change from the client's last visit. e. The client reports frequent fetal movements (kicks) throughout the day. f. The client reports a gush of fluid from the perineal region.
Answer: a,b,d,f a. The client reports experiencing regular contractions every 5 minutes. b. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation). d. The health care provider has documented pelvic change from the client's last visit. f. The client reports a gush of fluid from the perineal region.
20. A nurse is caring for several women in labor. The nurse determines that which woman is the latent phase of labor? A. contractions every 5 minutes, cervical dilation 3 cm B. contractions every 3 minutes, cervical dilation 6 cm C. contractions every 2 1/2 minutes, cervical dilation 8 cm D. contractions every 1 minute, cervical dilation 9 cm
Answer: A Rationale: Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent phase. Contractions every 3 minutes with cervical dilation of 6 cm, contractions every 2½ minutes with cervical dilation of 8 cm, and contractions every 1 minute with cervical dilation of 9 cm suggest the active phase of labor.
18. The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase? A. increment B. acme C. peak D. decrement
Answer: A Rationale: Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.
12. 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? A. frank B. full C. complete D. footling
Answer: A Rationale: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.
22. During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A. "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B. "Since this is your first pregnancy, you can estimate it will be about 10 hours." C. "It will depend on how big the baby is when you go into labor." D. "Time isn't important; your health and the baby's health are key."
Answer: A Rationale: It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last. There is no way to estimate the likely strength and frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the complex fetal rotations needed for an efficient labor will take place properly. All of these factors are unknowns when a woman starts labor. Telling the woman an approximate time would be inappropriate because there is no way to determine the length of labor. It is highly individualized. Although fetal size and maternal and fetal health are important considerations, these responses do not address the woman's concern.
2. A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. uterus becomes globular B. fetal head at vaginal opening C. umbilical cord shortens D. mucous plug is expelled
Answer: A Rationale: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.
27. A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why." Which response by the nurse would be most appropriate? A. "You had a burst of epinephrine, which is common before labor." B. "You were trying to get everything ready for your baby." C. "You felt your mind telling you that you were about to go into labor." D. "You were looking forward to the birth of your baby."
Answer: A Rationale: Some women report a sudden increase in energy before labor. This is sometimes referred to as nesting because many women will focus this energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household. The increased energy level usually occurs 24 to 48 hours before the onset of labor. It is thought to be the result of an increase in epinephrine (adrenaline) release caused by a decrease in progesterone. The burst of energy is unrelated to getting everything ready, the mind telling the woman that she will be going into labor, or looking forward to the birth.
23. A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis? A. sutures B. fontanelles C. frontal bones D. biparietal diameter
Answer: A Rationale: Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones, along with the parietal and occipital bones are bones of the cranium that are soft and pliable. The biparietal diameter is an important diameter that can affect the birth process.
30. A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include? A. implementing measures for a vaginal birth B. preparing the client for a cesarean birth C. assisting with artificial rupture of the membranes D. instituting continuous internal fetal monitoring
Answer: A Rationale: The fetal presentation and position is left occiput anterior position or LOA, which is the most common and most favorable fetal position for birth. LOA along with right occiput anterior position are optimal positions for vaginal birth. Therefore the nurse should implement measures for a vaginal birth. This fetal presentation is not an indication for cesarean birth. Nor is there need for artificially rupturing the membranes. Continuous internal fetal monitoring would be warranted if the woman or fetus was considered to be high risk.
8. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A. latent phase of the first stage. B. active phase of the first stage. C. pelvic phase of the second stage. D. early phase of the third stage.
Answer: A Rationale: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.
26. A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply. A. cervical dilation of 6 cm B. contractions every 2 to 3 minutes C. cervical effacement of 30% D. contractions every 90 seconds E. strong desire to push
Answer: A, B Rationale: During the active phase, the cervix usually dilates from 6 to 10 cm, with 40% to 100% effacement taking place. Contractions become more frequent, occurring every 2-5 min and increase in duration (45 to 60 seconds). Effacement of 30% reflects the latent phase. Contractions occurring every 90 seconds suggest the second stage of labor. A strong urge to push reflects the later perineal phase of the second stage of labor.
14. A nurse is conducting an in-service program for a group of nurses working in the labor and birth suite of the facility. After teaching the group about the factors affecting the labor process, the nurse determines that the teaching was successful when the group identifies which component as part of the true pelvis? Select all that apply. A. pelvic inlet B. cervix C. mid pelvis D. pelvic outlet E. vagina F. pelvic floor muscles
Answer: A, C, D Rationale: The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.
21. A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply. A. presence of a support partner B. view of birth as a stressor C. low anxiety level D. fear of loss of control E. participation in a pregnancy exercise program
Answer: A, C, E Rationale: Numerous factors can affect a woman's coping ability during labor and birth. Having the presence and support of a valued partner during labor, engaging in exercise during pregnancy, viewing the birthing experience as a meaningful rather than stressful event, and a low anxiety level can promote a woman's ability to cope. Excessive anxiety may interfere with the labor progress, and fear of labor and loss of control may enhance pain perception, increasing the fear.
17. A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include? Select all that apply. A. internal rotation B. abduction C. descent D. pronation E. flexion
Answer: A, C, E Rationale: The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.
3. When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? A. extent of opening to its widest diameter B. degree of thinning C. passage of the mucous plug D. fetal presenting part
Answer: B Rationale: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
13. A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event has most likely occurred? A. cervical dilation B. lightening C. bloody show D. Braxton Hicks contractions
Answer: B Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor. Braxton Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.
11. 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? A. The bony pelvis plays a lesser role during labor than soft tissue. B. The pelvic outlet is associated with the true pelvis. C. The false pelvis lies below the imaginary linea terminalis. D. The false pelvis is the passageway through which the fetus travels.
Answer: B Rationale: The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.
9. A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted? A. platypelloid B. gynecoid C. android D. anthropoid
Answer: B Rationale: The most favorable pelvic shape for vaginal birth is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth, but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.
25. A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? A. regular contractions B. cervical dilation (dilatation) C. fetal movement through the birth canal D. placental separation
Answer: B Rationale: The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.
1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A. "I'm feeling contractions mostly in my back." B. "My contractions are about 6 minutes apart and regular." C. "The contractions slow down when I walk around." D. "If I try to talk to my partner during a contraction, I can't."
Answer: C Rationale: False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.
29. Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A. -2 B. -1 C. 0 D. +1
Answer: C Rationale: Fetal engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.
15. A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use? A. flexion B. extension C. longitudinal D. cephalic
Answer: C Rationale: Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are three primary lies: longitudinal, oblique, and transverse. Flexion and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal presentation.
6. A client has not received any medication during her labor. She is having frequent contractions about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A. latent phase of the first stage of labor. B. perineal phase of the first stage of labor. C. late active phase of the first stage of labor. D. early phase of the third stage of labor.
Answer: C Rationale: Late in the active phase of labor, contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies (moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in the serious work of her labor. She limits interactions with those in the room. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of the second stage is the period of active pushing. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta
24. Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A. -2 B. -1 C. 0 D. +1
Answer: C Rationale: Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations.
16. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? A. occiput B. face C. buttocks D. shoulder
Answer: C Rationale: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation.
5. A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A. supine B. lithotomy C. upright D. knee-chest
Answer: C Rationale: The use of any upright position helps to reduce the length of labor. Research shows that women who assumed the upright position during the first stage of labor experienced significant improvement in the progress of labor, faster fetal head descent, significant reduction of pain, and a good Apgar score. Additionally, studies show that recumbent positions result in supine hypotension, diminishing uterine activity and reducing the dimensions of the pelvic outlet. The knee-chest position would assist in rotating the fetus in a posterior position.
19. A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction? A. heart rate increase from 76 bpm to 90 bpm B. blood pressure rise from 110/60 mm Hg to 120/74 C. white blood cell count of 12,000 cells/mm3 D. respiratory rate of 10 breaths/minute
Answer: D Rationale: During labor, the mother experiences various physiologic responses including an increase in heart rate by 10 to 20 bpm, a rise in blood pressure by up to 35 mm Hg during a contraction, an increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma, and an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism. A drop in respiratory rate would be a cause for concern.
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. a. begin irregularly but become regular and predictable b. felt first in lower back and sweep around to the abdomen in a wave c. increase in duration, frequency, and intensity d. begin and remain irregular e. felt first abdominally and remain confined to the abdomen and groin f. often disappear with ambulation or sleep
a. begin irregularly but become regular and predictable b. felt first in lower back and sweep around to the abdomen in a wave c. increase in duration, frequency, and intensity True contractions begin irregularly but become regular and predictable; are felt first in the lower back and sweep around to the abdomen in a wave; continue no matter what the pregnant client's level of activity; increase in duration, frequency, and intensity; and achieve cervical dilatation. False (Braxton Hicks) contractions begin and remain irregular; are felt first abdominally and remain confined to the abdomen and groin; often disappear with ambulation or sleep; do not increase in duration, frequency, or intensity; and do not achieve cervical dilatation.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? a. transition phase b. latent phase c. active phase d. early phase
a. transition phase The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation (dilatation) of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.
A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response? a. "It is the measurement between the ischial tuberosity and the pubis." b. "It is a measurement to determine if the pelvis size is adequate for a vaginal birth." c. "It is the smallest diameter of the pelvic outlet." d. "It is the largest diameter of the pelvic outlet."
b. "It is a measurement to determine if the pelvis size is adequate for a vaginal birth." Since the obstetric conjugate cannot be measured directly, the practitioner must estimate the size. To obtain this estimate, the practitioner measures the diagonal conjugate, which extends from the symphysis pubis to the sacral promontory.
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. a. Testosterone b. Oxytocin c. Thyroxine d. Progesterone e. Prostaglandins f. Insulin
b. Oxytocin d. Progesterone e. Prostaglandins There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
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? a. flexion b. engagement c. extension d. expulsion
b. engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
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? a. uterine abnormalities b. fetal anomalies c. congenital anomalies d. birth after due date
b. fetal anomalies The nurse, along with the primary care provider, has to assess for fetal anomalies, which are usually associated with a shoulder presentation during a vaginal birth. The other conditions include placenta previa and multiple gestations. Uterine abnormalities, congenital anomalies, and prematurity are conditions associated with a breech presentation of the fetus during a vaginal birth.
A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation? a. relationship of the presenting part to the maternal pelvis b. part of the fetal body entering the maternal pelvis first c. relation of the fetal presenting part to the maternal ischial spine d. relation of the different fetal body parts to one another
b. part of the fetal body entering the maternal pelvis first The term presentation is the part of the fetal body that is entering the maternal pelvis first. The relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. The relation of the fetal presenting part to the maternal ischial spine is termed the station.
The nurse is caring for four clients within the labor and delivery unit. Which client does the nurse anticipate will be sent home? a. The primigravida who is effaced, having intense contractions but at irregular intervals and dilation (dilatation) is 6 cm b. The multipara who just experienced lightening and is having contractions 7 minutes apart. c. The primigravida who has a thinning cervix and a dilation of 3 cm d. The multipara who is effaced with dilation of 4 cm.
c. The primigravida who has a thinning cervix and a dilation of 3 cm The primigravida who is not fully effaced with a low (3 cm out of 10) dilation (dilatation) will be sent home. At this point, it is unclear if the client is in true or false labor. Multiparous women typically have shorter labors, thus the nurse must consider this fact when anticipating health care provider decisions. The primigravida who is effaced and dilated 6 cm is definitely in labor even if the contractions are at irregular intervals.
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor? a. second b. first, latent c. first, active d. third
c. first, active Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor, which is characterized by cervical dilation (dilatation) of 4 to 7 cm. Regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and at -1 station. The second stage of labor begins when the cervix is 10 cm dilated. The first latent phase is characterized by the onset of regular contractions and cervical dilation (dilatation) of 0 to 4 cm. The third stage of labor is from birth of the infant to completed delivery of the placenta.
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? a. active b. stage two c. latent d. stage three
c. latent The client in labor undergoes numerous psychologic adaptations during labor. During the latent phase, the client is often talkative and happy, and yet anxious. During active phase, the client may show fear and anger. Both the latent and active phases occur during stage 1. During stages 2 and, the client may remain positive, but the work of labor is very intense.
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? a. It helps the woman in labor to save energy. b. It facilitates vaginal examinations. c. It facilitates external belt adjustment. d. It helps to rotate the fetus in a posterior position.
d. It helps to rotate the fetus in a posterior position. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.
A nurse is monitoring a client in labor. Which assessment finding is most concerning to the nurse? a. Client begins vomiting. b. Blood pressure is 128/82 mm Hg. c. Respiratory rate is 22 breaths/minute. d. Temperature is 101.6°F (38.7°C).
d. Temperature is 101.6°F (38.7°C). Although slight temperature elevations are normal during labor, a temperature of 101.6°F (38.7°C) indicates an infection and should be reported to the health care provider. As the client progresses through birth, numerous physiologic responses occur that assist the client to adapt to the laboring process. Some of these changes include heart rate increasing by 10 to 20 beats/min; blood pressure increases by up to 35 mm Hg; and respiratory rate increases as more oxygen is consumed. Nausea and vomiting are common during labor, especially during the active phase, due to decreased gastric motility.
The nurse has been monitoring a multipara client for several hours. The client cries out that the contractions are getting harder and that they cannot continue with the labor process. The nurse notes the client is very irritable, nauseated, annoyed, and does not want to be left alone. Based on the assessment which action should the nurse take next? a.Reassure the client that they can complete the laboring process. b.Administer ondansetron as prescribed. c.Notify the primary health care provider. d.Assess the client's cervix.
d.Assess the client's cervix. The reaction of the client is indicative of being near the end of the active phase of labor, stage 1. The nurse would first assess the client's cervix to determine dilation (dilatation) status. The client may be ready to begin the birth process. After assessing the cervix, the nurse would determine what action to take next. The nurse would support the client and reassure the client that they can complete the labor and birth process. The nurse would discuss options to help the client in the process, such as breathing techniques, pain medication, imagery, or other methods. If the client's cervix is fully dilated, the nurse would notify the primary health care provider and prepare the client for the birth process. Ondansetron could be administered if the client is not ready for the birth process.
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 lying on her back with feet in stirrups squatting semi-Fowler position
position of comfort for the mother
4. A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? A. increased energy level with alternating strong and weak contractions B. moderately strong contractions every 4 minutes, lasting about 1 minute C. contractions noted in the front of abdomen that stop when she walks D. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds
Answer: B Rationale: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.
10. A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? A. "Call us back when you start having contractions." B. "Come to the clinic or emergency department for an evaluation." C. "Drink 3 to 4 glasses of water and lie down." D. "Come in as soon as you feel the urge to push."
Answer: B Rationale: When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.
Uterine contractions are assesses according to frequency, duration and ____________
Intensity
In which manner is the fetal status best assessed during the active and transition stages of labor? a. Fetal heart rate at the peak of a contraction b. Fetal movement on the tocometer c. Fetal heart rate between contractions d. Fetal kicks over a 1-minute period
a. Fetal heart rate at the peak of a contraction Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best indicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.
The five "Ps" of labor are: a. passageway, passenger, position, powers, psych. b. passenger, posture, position, presentation, psych. c. passenger, position, presentation, pushing, psych. d. passenger, position, powers, presentation, psych.
a. passageway, passenger, position, powers, psych. The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? a.False pelvis b. Cervix c. Perineum d. Uterus
b. Cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
A nurse is providing education to pregnant clients in birth education classes. Which nursing interventions would the nurse include to promote positive learning? Select all that apply. a. Instruct the class to make environmental changes at home. b. Instruct the class to include "self" time each day. c. Encourage the clients to remain positive about the pregnancy. d. Provide information about all procedures in the birthing process.
c. Encourage the clients to remain positive about the pregnancy. d. Provide information about all procedures in the birthing process. Clients should be encouraged to be positive throughout pregnancy. Providing all information about the birthing process will aid in being positive and informed. The nurse should encourage clients to have a support person. It may not be appropriate to be promote "self" time or being alone, or to change the home environment.