PrepU: Chapter 13: Labor and Birth Process

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? Fetal position Fetal lie Fetal presentation Fetal attitude

Fetal lie

Which is the most important nursing assessment of the mother during the fourth stage of labor? Heart rate Hemorrhage The mother's psyche Blood pressure

Hemorrhage

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? cephalic shoulder breech vertex

shoulder

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 client can be sent home. The frequency of the contractions is every 5 minutes. The client is in active labor. The duration of the contractions is every 5 minutes.

The frequency of the contractions is every 5 minutes.

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? "This is not normal unless you are in active labor; come to the hospital and be checked." "That is something we expect with a second or third baby, but because it is your first, you need to be checked." "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital." "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

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 has descended down the birth canal. The fetus is in the true pelvis and engaged. The client is fully effaced. The fetus is floating high in the pelvis.

The fetus is in the true pelvis and engaged.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? position attitude lie presentation

lie

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? decrease in prostaglandins, leading to myometrium contractions change in estrogen-to-progesterone ratio decrease in the level of estrogen decrease in number of oxytocin receptors

change in estrogen-to-progesterone ratio

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? restitution descent crowning engagement

crowning

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: relieved by walking. lasting about 30 seconds. occurring in the abdomen and groin. occurring about every 5 minutes.

occurring about every 5 minutes.

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. Insulin Thyroxine Prostaglandins Testosterone Progesterone Oxytocin

Oxytocin Progesterone Prostaglandins

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is flat and narrow, making it extremely difficult for the neonate to pass through." "It is elongated, the width is roomy, but the length is narrow." "It is rounded in shape and allows ample room for the neonate to fit through the passageway." "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally."

"It is rounded in shape and allows ample room for the neonate to fit through the passageway."

A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours? "There has been no further dilation; effacement is progressing." Don't mention anything to the client yet; wait for further dilatation to occur. "You are still 2 cm dilated, but the cervix is thinning out nicely." "You haven't dilated any further, but hang in there; it will happen eventually."

"You are still 2 cm dilated, but the cervix is thinning out nicely."

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? Give the medication as an intramuscular injection using the Z-track technique. Assist with insertion of a central venous access device for administration. Give the medication orally every hour for the first 4 hours. Administer the medication piggybacked into a primary IV line using a pump.

Administer the medication piggybacked into a primary IV line using a pump.

A nurse is monitoring a woman in labor. Which assessment finding is most concerning to the nurse? Blood pressure is 128/82 mm Hg. Respiratory rate is 22 breaths/minute. Temperature is 101.6°F (38.7°C). Client begins vomiting.

Temperature is 101.6°F (38.7°C).

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 client is fully effaced. The fetus has descended down the birth canal. The fetus is in the true pelvis and engaged. The fetus is floating high in the pelvis.

The fetus is in the true pelvis and engaged.

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? increase in fetal oxygen pressure decrease in circulation and perfusion to the fetus decrease in arterial carbon dioxide pressure increase in fetal breathing movements

decrease in circulation and perfusion to the fetus

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? dilation (dilatation) crowning effacement molding

effacement

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: intensity. peak. frequency. duration.

frequency

A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client? Select all that apply. chewing gum prescribed pain killers acupressure massaging hand holding

hand holding massaging acupressure

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 slight decrease in body temperature increase in respiratory rate increase in gastric emptying and pH

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? stage three stage two latent phase transition phase

latent phase

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 fetus is sitting cross-legged above the cervix. the buttocks are presenting first with both legs extended up toward the face. one leg is presenting. one arm is presenting.

the buttocks are presenting first with both legs extended up toward the face

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? 3 to 4 8 to 10 0 to 2 5 to 7

8 to 10

Which fetal adaptation is anticipated in a vaginal birth? Select all that apply. Decreased intracranial pressure Excretion of respiratory tract mucus Circumoral cyanosis after birth Changing heart rate during contractions Decreasing pH throughout labor

Decreasing pH throughout labor Changing heart rate during contractions Excretion of respiratory tract mucus

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? The station in which the fetus is located Maternal request for pain medication Fetal heart rate in relation to contractions Maternal heart rate and blood pressure

Fetal heart rate in relation to contractions

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 at 60° to that of client. Long axis of fetus is at 45° to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is parallel to that of client.

Long axis of fetus is perpendicular to that of client.

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? Pant while pushing. Push with contractions and rest between them. Hold the breath while pushing during contractions. Begin pushing as soon as the cervix has dilated to 8 cm.

Push with contractions and rest between them.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client experiences her first full contraction. The client's cervix is fully dilated. The client has contractions once every two minutes. The infant is born.

The client's cervix is fully dilated.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client has contractions once every two minutes. The infant is born. The client experiences her first full contraction. The client experiences her first full contraction. The client's cervix is fully dilated.

The client's cervix is fully dilated.

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 cause discomfort over the top of uterus subside when walking around and use the lateral position remain irregular with the same intensity

increase even if relaxing and taking a shower

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. placenta previa. rupture of the membranes. start of labor.

lightening