NR 330 Parent/Child Nursing Chapter 13 Labor & Birth Process PrepU Answers

Assessment of a pregnant woman in labor reveals that the fetal attitude is normal. The nurse interprets this as indicating which information? Select all that apply.

-chin is on the chest -legs are flexed at the knees

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

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

The nurse is preparing to teach a group of soon-to-be new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?

shoulder

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 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 (first) phase

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

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

Which cardinal movement of delivery is the nurse correct to document by station?

Descent

Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready.

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage

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.

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur?

cervical ripening and softening

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?

cervix

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

fetal position

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

Which feature would alert the nurse that the client is in the transition phase of labor?

beginning urge to bear down

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 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

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.

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

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."

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

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 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?

android

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

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

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

increased white blood cell count

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."

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 promontory is 13 cm?

-11 cm -The obstetric conjugate measurement is the smallest diameter of the inlet through which the fetus must pass. This cannot be measured directly. This is determined by subtracting 1.5 cm to 2 cm from the diagonal conjugate, which extends from the symphysis pubis to the sacral promontory.

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.