Maternity: Chpt. 13

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?

"The presenting part is at the true pelvis and is engaged."

The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:

1 cm above the ischial spines

The nurse is assisting the health care provider with the pelvic assessment of a pregnant client. The nurse concludes that the obstetric conjugate will be how long if the distance between the symphysis pubis and sacral promontary is 13 cm?

11 cm

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?

8-10cm

After delivery of the placenta, a patient's uterus is sluggish to contract. What should the nurse prepare to do to assist the patient at this time?

Administer oxytocin (pitocin) as prescribed

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

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?

First, Active

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 HR, BP, and RR

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

Increase WBC

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?

Is narrow transversely

A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. The nurse predicts the woman is close to labor based on which assessment finding?

Nesting

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

After pelvic measurements, a patient who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this?

Passageway

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

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 2020 related to women in labor?

Reduce the rate of cesarean births among low-risk births

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 patient in labor is being encouraged to push with contractions. In which position should the nurse assist to help the patient at this time?

Semi-Fowler's position with legs bent against the abdomen

The nurse providing care to patients in the labor and delivery suite desires to support the 2020 National Health Goals to reduce maternal and infant mortality after labor and birth. Which action should the nurse perform to support these goals?

Support laboring patients through the use of controlled breathing techniques

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

The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?

The cervix is softening

While conducting Leopold maneuvers, the nurse determines that the fourth maneuver does not need to be done. What information caused the nurse to make this decision?

The fetus is not in a cephalic presentation

The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with which?

The powers

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as:

frequency

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 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

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

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care?

A woman may spend time thinking about what is happening to her

A client in labor has been admitted to the labor and birth suite. The nurse assessing her notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?

part of the fetal body entering the maternal pelvis first

The five "Ps" of labor are:

passageway, passenger, position, powers, psych

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

Which of the following would be a danger signal of labor for a woman in labor?

Meconium-stained amniotic fluid

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?

increase in duration, frequency, and intensity; felt first in lower back and sweep around to the abdomen in a wave; begin irregularly but become regular and predictable

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 educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?

poorly ossified bones of the cranial vault

A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?

transverse (biparietal)

A primigravidia 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."

A nurse is admitting a client who presents in active labor at 41 weeks' gestation. The nurse prepares for the possibility of a cesarean delivery after noting the client has which type of pelvis documented?

Andriod

When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanelle. Which description would the nurse include?

Approximately 2-3cm in size

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

During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs?

Assess fetal heart rate for fetal safety

A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next?

Continue to monitor the client

A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phase based on which assessment findings? Select all that apply.

Contractions lasting up to 60s; cervical dilation 6cm

The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor?

Ecchymosis with edema on the scalp is where the infant was pushed out of the canal.

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply.

Encourage the client to have a sense of mastery and self-control; Encourage the client to have a positive reaction to pregnancy; Provide the client clear information on procedures involved

The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus?

Facing the right anterior pelvic quadrant

The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply

False labor contractions do not increase in duration, frequency, and intensity; False labor contractions are irregular

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

During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding?

Fetal heart rate declining late with contractions and remaining depressed

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 to be an advantage of adopting a kneeling position during labor?

It helps to rotate fetus in a posterior position

After assessment, the nurse determines that a pregnant patient's fetus has a face presentation that is pointing to the patient's left side with transverse pointing. How should the nurse document this assessment finding?

LMT

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

Place the following stages of labor in order from what occurs first to last. All options must be used.

Latent, active, transition phases; Second phase; Third phase

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:

Lightening

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 determining care for a patient entering the active phase of labor. Which outcome would be the most appropriate for the patient at this time?

Patient will adjust body to attain the most comfortable position

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most?

Positive reinforcement

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

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

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?

Significant head molding

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize?

The completion of the third stage of labor

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

Assessment of a pregnant client reveals that she is experiencing Braxton -Hicks contractions. Which of the following would the nurse explain as the cause of these contractions?

Uterine distention

Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.

Vaginal rugae stretch and smooth out, cervix dilates to 10cm and cervix softens

A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible?

Women should be able to move about freely throughout labor

When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories?

change in estrogen-to-progesterone ratio

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 of cervix diameter to 10 cm

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 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 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

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 constrict the uterine blood vessels

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?

transition phase

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 in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation?

Catecholamines

When educating a group of nursing students about the different types of pelvis, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type?

Platypelloid