Process of Labor & Birth

A woman with a history of two stillbirths is in the active phase of the first stage of labor in the high-risk OB unit. How often should the nurse anticipate monitoring fetal heart tones (FHTs)? A. Continuously B. Every 5 minutes C. Every 15 minutes D. Every 30 minutes

A ~ Women with certain complications, including a history of stillbirth, a high-risk pregnancy (preeclampsia-eclampsia, placenta previa, abruptio placentae, multiple gestations, prolonged or premature rupture of the membranes), induction with oxytocin, or a problem with FHT, should have FHT monitored continuously.

At 9:00 a.m., the OB nurse assesses fetal station at 0. The laboring woman has strong, regular contractions. At 10:30 a.m., the nurse again assesses fetal station at 0. What action by the nurse is best? A. Document the findings and continue to assess frequently. B. Encourage the woman to bear down during contractions. C. Increase the womans IV fluid rate and reassess in 30 minutes. D. Inform the provider and prepare for possible cesarean delivery.

D ~ As labor advances and the presenting fetal part descends, the station should progress to a numerically higher positive station (numerically higher positive number). If the station does not change in the presence of strong, regular contractions, this may indicate a problem with the relationship between the maternal pelvis and the fetus (cephalopelvic disproportion). The nurse should inform the provider and prepare for a possible cesarean delivery. Documentation should occur in all situations, but more action is needed. Increasing the IV fluid rate is not warranted. The woman should be encouraged to bear down only after the cervix is totally dilated.

A nurse assesses a newborn as follows: heart rate is 112 beats/minute; respiratory effort: slow, irregular, with a weak cry; muscle tone: some flexion of the extremities; reflex irritability: grimace; color: pink. What Apgar score does the nurse give this infant?

7 ~ Heart rate: 2; respiratory effort: 1; tone: 1; reflex irritability: 1; color: 2; total = 7

A nurse is caring for a woman in labor whose fetal heart rate tracings show late decelerations. What observation by the nurse indicates that an important outcome for the nursing diagnosis of impaired fetal gas exchange has been met? A. Fetal heart monitor shows accelerations to contractions. B. Fetal heart monitor shows variable decelerations. C. Fetal heart rate rises to180 beats/minute. D. Maternal heart rate returns to baseline between contractions.

A ~ Accelerations in response to contractions are generally considered a sign of fetal well-being, and this variability is an important predictor of adequate fetal oxygenation. If nursing actions for late decelerations have been effective, the nurse should note encouraging fetal signs. The other options do not indicate encouraging fetal signs, nor do they indicate that impaired fetal gas exchange has been resolved.

What nursing action best helps to prevent perineal lacerations during birth? A. Providing adequate coaching on pushing and breathing B. Applying warm compresses to the perineum C. Helping the woman to squat during labor D. Performing an episiotomy early in labor

A ~ Adequate coaching on pushing and breathing helps the woman deliver the fetal head in a controlled manner, which reduces the likelihood and/or severity of perineal lacerations. Applying warm compresses to the perineum is one of many complementary therapies used to reduce birth trauma. However, results have been inconsistent.

A nurse notes fetal heart rate decelerations that appear to start just prior to a uterine contraction with the fetal heart rate returning to normal by the end of the contraction. How does the nurse document this finding? A. Early deceleration B. Late deceleration C. Mild deceleration D. Variable deceleration

A ~ An early deceleration looks like the mirror image of a uterine contraction on the fetal heart monitor. The onset of the deceleration begins near the onset of the contraction, the lowest part of the deceleration occurs at the peak of contraction, and the fetal heart rate returns to baseline by the end of the contraction. Early decelerations are usually benign and well tolerated by the fetus. Late decelerations have a late onset and do not resolve until after the contraction has ended. Mild is not a term used to describe decelerations. Variable decelerations are inconsistent in their onset, peak, and duration.

A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first? A. Assess the maternal temperature and call the primary care provider. B. Document the findings in the patients chart. C. Have the woman get up and walk or change position. D. Perform a vaginal exam to assess for cord compression.

A ~ Causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal medications (such as parasympathetic drugs and tocolytic drugs), infection, fetal anemia, and maternal hyperthyroidism. The nurse should quickly assess the maternal temperature and call the provider, as the tocolytic medication may need to be slowed or stopped. The findings do need to be documented, but further action is needed. The woman should not get up and walk, as this will further stimulate the fetus. Checking for cord compression is an important intervention with fetal bradycardia.

A woman arrives at the birthing unit complaining of frequent strong contractions that begin in her back and cannot be relieved by walking or changing positions. What action by the nurse is most appropriate? A. Assess the woman for rupture of membranes. B. Immediately notify the womans primary care provider. C. Reassure the woman and send her home. D. Review the signs of true labor with the woman.

A ~ Distinguishing true labor from false labor can be difficult. True labor contractions occur with regularity, increased in frequency and duration, and usually begin in the woman's lower back and radiate to the abdomen. Based on the woman's description, the contractions likely are indicative of true labor, so she should be assessed further, including assessment for rupture of membranes. There is no urgent need to notify her primary care provider until further assessment is completed. She should not be sent home, nor does she need more education on the signs of true labor.

The perinatal nurse is describing the process of fetal engagement to a group of first-time parents in a prenatal class. The nurse explains that in primigravidas, the usual time for engagement to occur is which of the following? A. 2 weeks before the due date B. 4 weeks before the due date C. 6 weeks before the due date D. During labor

A ~ Engagement is said to have occurred when the widest diameter of the fetal presenting part has passed through the pelvic inlet. In primigravidas, engagement usually occurs approximately 2 weeks before the due date. In multiparas, engagement may occur many weeks before the onset of labor, or it may take place during labor.

A new nurse is preparing to assess the fetal heart rate response to stimulation with vibroacoustic stimulation. What action by the new nurse would prompt the precepting nurse to intervene? A. Nurse attempts stimulation in the presence of fetal bradycardia. B. Nurse attempts stimulation in the presence of ruptured membranes. C. Nurse places stimulation device over the fetal head for 1 to 2 seconds. D. Nurse waits until fetal heart rate is at baseline before initiating the stimulation.

A ~ Fetal stimulation should occur when the fetal heart rate is at baseline, and not in the presence of decelerations or bradycardia. If the nurse attempts to stimulate the fetal heart rate in a bradycardic fetus, the preceptor should intervene. The other options are correct steps in the procedure (stimulation can occur in the presence or absence of ruptured membranes).

A nurse is caring for a new mother during the fourth stage of labor and assesses the following: patient has soaked two peri-pads in 45 minutes, pulse is 118 beats/minute, and blood pressure is 90/62 mm Hg. Which action by the nurse is most important? A. Assess the firmness of the patients uterus. B. Document the findings and reassess in 15 minutes. C. Encourage the woman to attempt breastfeeding. D. Escort the woman to the bathroom to void.

A ~ Hypotension, tachycardia, excessive bleeding (more than one peri-pad in the first hour), and a boggy, non-contracting uterus are all danger signs of postpartum hemorrhage. Based on this woman's signs and symptoms, the nurse should assess her uterus and, if necessary, begin uterine massage. Documentation needs to be thorough, but further action is needed. Breastfeeding does stimulate the uterus, but this action is not the priority in a possible emergent situation. A hypotensive woman should not be ambulated.

The nurse assesses a woman in labor and finds that her cervix is dilated to 9 cm. The nurse documents the woman to be in what phase of labor? A. First stage B. Second stage C. Third stage D. Fourth stage

A ~ The first stage of labor begins with regular uterine contractions and ends when the cervix is fully dilated (10 cm). The second stage of labor begins with full dilation of the cervix and ends with the birth of the baby. The third stage of labor is the period of time from the birth of the baby to the complete delivery of the placenta. The fourth stage of labor is the period of maternal physiological adjustment that occurs from the time of delivery of the placenta through the first 1 to 2 hours after birth.

What important nursing action occurs right after the third stage of labor? A. Assess the placenta for complete expulsion. B. Assist the woman with effective pushing. C. Provide a lactation consultation if desired. D. Warm the baby and place it in an incubator.

A ~ The third stage of labor is the time between the birth of the baby until the complete delivery of the placenta. An important nursing action is to assure that the entire placenta has been delivered. There is no need to assist with pushing as the baby has already been born. This is a good time to facilitate bonding and to attempt breastfeeding if desired, but too early to initiate a lactation consultation. The stable baby should be placed on the mothers abdomen.

The nurse instructs the pregnant woman to report any rupture of the membranes along with a description of the fluid. Which of the following would the nurse evaluate as normal amniotic fluid? (Select all that apply.) A. Clear liquid B. Contains white specks C. Presence of lanugo D. Slight ammonia odor E. Yellow-greenish color

A, B, C ~ Amniotic fluid should be clear and odorless. It may contain white specks and/or fetal hair (lanugo). Yellowish-green tinged fluid may indicate infection or the presence of meconium.

The perinatal nurse obtains valuable information from a vaginal examination. Which of the following assessments from this examination should the nurse document? (Select all that apply.) A. Extent of cervical dilation B. Fetal presentation C. Presence of cervical effacement D. Status of the amniotic membranes E. Strength of uterine contractions

A, B, C, D ~ The vaginal examination provides important information regarding the diameter of the opening of the cervix, which ranges from 1 cm (not dilated) to 10 cm (fully dilated); the status of the amniotic membranes (ruptured or intact); and the fetal presentation and the station or the extent of the fetal descent through the maternal pelvis. A trained examiner can also assess effacement of the cervix during a vaginal exam.

A woman is admitted in labor. The perinatal nurse would demonstrate cultural sensitivity by assessing the patient for which of the following? (Select all that apply.) A. Need for an interpreter B. Pain management and coping techniques C. Preference for food during labor D. Preferences for touch during labor E. Support person during labor

A, B, C, D, E ~ Culturally oriented views of childbirth help to shape the womans expectations and ongoing perceptions of the birth experience. The nurses understanding of the cultural values and expectations attached to childbirth provide a meaningful framework on which to plan and deliver sensitive, appropriate care. Cultural considerations for the laboring woman encompass many elements of the birth experience, including choice of a birth support person, strategies for coping with contractions, pain expression and relief, language preference, use of touch, and food preferences.

A nursing instructor explains to the class of nursing students that the critical factors affecting the progress of labor include which of the following? (Select all that apply.) A. Passageway B. Passageway + Passenger C. Passenger D. Productivity E. Psychosocial factors

A, B, C, E ~ The 5 Ps of labor are Powers, Passageway, Passenger, Passageway + Passenger, and Psychosocial influences. Productivity is not included.

A nurse is assisting with an amnioinfusion. What critical nursing actions are included in this procedure? (Select all that apply.) A. Assessing the maternal temperature B. Assembling equipment C. Documenting fluid exiting the vagina D. Maintaining sterile technique E. Monitoring the fetal heart rate

A, B, C, E ~ The critical nursing actions during this procedure are assembling the equipment; monitoring the fetal heart rate, contraction status, and maternal temperature; and verifying and documenting that the infused fluid exits the vagina. The nurse is not performing the procedure; it is up to the provider to maintain sterile technique. Of course the nurse should be vigilant that sterile technique is not breached.

The nurse is assessing a woman in labor. What techniques are vital for the nurse to use during this assessment? (Select all that apply.) A. Auscultation B. Inspection C. Interviewing D. Percussion E. Palpation

A, B, C, E ~ The nurse uses the skills of interviewing, inspection (observation), palpation, and auscultation to assess the woman in labor. Percussion is not generally used in this assessment.

The nurse assessing a woman in the third stage of labor would expect which of the following findings? (Select all that apply.) A. Cramping as the placenta delivers B. Mother crying or feeling relieved C. Presence of lochia rubra with small clots possible D. Uterus rises upward E. Vital signs returning to pre-labor values

A, B, D ~ During the third stage of labor, the mother may experience cramping as the placenta is expelled, after which the uterus will rise upward. The mother may cry or express relief that labor is over. Lochia rubra and pre-labor vital signs are seen in the fourth stage of labor.

The perinatal nurse knows that a cephalic presentation has which of the following advantages to the woman in labor? (Select all that apply.) A. Fetal skull bones have the ability to mold during birth. B. The largest part of the fetus is presenting first. C. The presenting part may not totally cover the cervix. D. The shape of the fetal head is optimal for cervical dilatation. E. The top of the fetal head assists with cervical effacement.

A, B, D ~ The following advantages are associated with a cephalic presentation: the fetal head is usually the largest part of the infant and after the fetal head is born, the rest of the body usually delivers without complications; the fetal head is capable of molding and there is sufficient time during labor and descent for molding of the fetal head to occur; molding helps the fetus to maneuver through the maternal birth passage; and the fetal head is smooth and round, which is the optimal shape to apply pressure to the cervix and to aid in dilation. Breech or malpresentations can lead to umbilical cord prolapse because the presenting part (e.g., a foot) may not totally cover the cervix. The presenting part does not influence effacement.

When calling the primary health-care provider regarding a woman's admission, the perinatal nurse includes which of the following information? (Select all that apply.) A. Gestational age and estimated date of birth B. Maternal and fetal vital signs C. Presence of support person(s) D. Status of other children E. Status of the fetal membranes

A, B, E ~ Critical information to relay to the physician or nurse-midwife includes the patient's name and age; gravidity and parity; gestational age and estimated date of delivery; labor status, pattern of contractions, cervical dilatation and effacement; fetal presentation and station; status of the fetal membranes; fetal heart rate and response to contractions; patients vital signs, especially blood pressure and temperature; any identified risk to maternal or fetal well-being; and the patients coping ability in response to labor. Presence of support persons and status of other children would not be critical information at this point.

The perinatal nurse knows that changes in the pelvic floor musculature that normally occur in labor include which of the following? (Select all that apply.) A. Eversion of the anus B. Exposure of the internal rectal wall C. Pulling downward on the levator ani muscles D. Rectum drawn upward and backward E. Thinning of the perineal body

A, B, E ~ Uterine contractions bring about changes in the pelvic floor musculature. The forces of labor cause the levator ani muscles and fascia of the pelvic floor to draw the rectum and vagina upward and forward. During descent, the fetal head exerts increasing pressure and causes thinning of the perineal body from 5 cm to less than 1 cm in thickness. Continued pressure causes the maternal anus to evert, and the interior rectal wall is exposed as the fetal head descends forward.

The nurse in the birthing unit is aware that according to the Emergency Medical Treatment and Active Labor Act (EMTALA), pregnant women should receive care for problems such as which of the following? (Select all that apply.) A. A history of recent trauma B. Contractions that occur 20 minutes apart C. Decreased fetal movement D. Rupture of the membranes E. Sexually transmitted infections

A, C, D ~ The federal regulation known as the Emergency Medical Treatment and Active Labor Act (EMTALA) was created to ensure that all women receive emergency treatment or active labor care whenever such treatment is sought. The nurse who is working in a birthing unit must be familiar with the full range of responsibilities included in the EMTALA regulations: (1) provide services to pregnant women when an urgent pregnancy problem such as labor, rupture of the membranes, decreased fetal movement, or recent trauma is experienced; and (2) fully document all relevant information to include assessment findings, interventions implemented, and the patients response to the care provided. Treatment would not be required for women whose contractions are 20 minutes apart or who may have sexually transmitted infections.

A nurse notes variable decelerations on the fetal heart monitor and is explaining them to the laboring woman and her partner. What information about these patterns does the nurse share? (Select all that apply.) A. Last at least 15 seconds B. Least common type of deceleration pattern C. May be a result of cord compression D. Occur at any time during a contraction E. Return to baseline within 4 minutes

A, C, D ~ Variable decelerations are inconsistent in the onset, peak, duration, and intensity. They are the most common type of deceleration pattern seen in labor. They last at least 15 seconds, occur any time during a contraction, and may be the result of cord compression. They return to baseline within 2 minutes.

A woman in labor seems to be progressing more slowly than expected. Which action should the nurse perform first? A. Administer oxygen by face mask. B. Assess the woman for a full bladder. C. Increase the rate of the IV fluids. D. Provide stimulants such as coffee.

B ~ A full bladder can hinder the progression of labor by slowing the descent of the fetus. A full bladder can also contribute to increased pain during contractions. The nurse should assess the woman for a full bladder. This is easy and quick to accomplish. The woman should be encouraged to void every 2 hours. The other options are not warranted.

A nurse assessing a fetal heart monitor notes minimal baseline variability not associated with a fetal sleep cycle. There is no change after fetal scalp stimulation. What action by the nurse is most important? A. Administer a bolus of IV fluids. B. Administer oxygen at 8-10 L/min per mask. C. Offer support to the patient and her partner. D. Prepare to assist with internal fetal monitoring.

B ~ All options are correct actions for the nurse to take in this situation. However, actions should be prioritized using the A (airway), B (breathing), C (circulation) method. The breathing action (administering oxygen) should occur prior to the circulation action (IV fluids) in the absence of any other data.

A woman and her partner are interested in exploring different birthing options. What action by the perinatal nurse would be most helpful? A. Advise the couple to ask for referrals from friends. B. Arrange tours of different birthing facilities. C. Give the couple brochures from different facilities. D. Refer to social work for an insurance review.

B ~ Although all options may be beneficial, the best way to help a couple explore birthing options is to encourage them to tour various facilities to gain an understanding of what to expect from the experience. Touring birthing units is often included in childbirth education.

A woman in the perinatal clinic reports a gush of vaginal fluid after sneezing. The nurse performs a Nitrazine tape test and documents that the tape is beige in color. What action should the nurse take? A. Ask the woman about recent sexual intercourse. B. Assess the woman for urinary incontinence. C. Arrange for the woman to be admitted to the birthing unit. D. Inquire if the woman has symptoms of a vaginal infection.

B ~ Amniotic fluid is alkaline with a pH between 6.5 and 7.5. When the alkaline amniotic fluid is exposed to Nitrazine tape, the tape turns blue-green, gray, or deep blue. Urine and vaginal secretions are usually acidic. Because the gush of fluid occurred after sneezing, the nurse should assess the woman for urinary incontinence (especially stress incontinence). The presence of semen or certain bacterial infections can also lead to an alkaline result. The woman does not need admission.

A woman who is 37 weeks pregnant calls the birthing center to report a gush of clear fluid from her vagina. What response by the nurse is best? A. Are you having any pain? B. Come in now to be evaluated. C. Did you have any trauma? D. It is too early for membrane rupture.

B ~ Any gush of fluid from a pregnant woman's vagina needs to be evaluated, even if there are no contractions. The other responses are not appropriate for this situation.

A nurse assesses fetal heart tones at 100 beats/minute. Which action by the nurse takes priority? A. Administer 100% oxygen. B. Assess the maternal heart rate. C. Notify the primary care provider. D. Turn the woman on her left side.

B ~ Causes of fetal bradycardia include late fetal hypoxia, medications (beta blockers), maternal hypotension, prolonged umbilical cord/fetal head compression, fetal bradyarrhythmias, uterine hyperstimulation, abruptio placentae, uterine rupture or vasa previa, or vagal stimulation during the second stage of labor. However, it is also possible that the maternal heart tones are mistakenly counted as fetal heart tones. The first action by the nurse is to assess the maternal heart rate to confirm that it is not being counted as the fetal heart rate. This is done whether the nurse is using a fetoscope or external fetal monitoring.

A woman who is 40 weeks pregnant calls the clinic to report that she noted a small amount of blood-tinged mucus on her toilet tissue this morning. What response by the nurse is most appropriate? A. Come to the clinic today for an examination. B. Labor will probably start within 48 hours. C. Lie on your left side and count fetal kicks. D. Stay on bedrest until your labor begins.

B ~ During pregnancy, the cervix is plugged with mucus. When effacement begins, small capillaries can rupture, leading to an expulsion of the blood-tinged mucus plug, called bloody show. Its presence often indicates that labor will begin in 24 to 48 hours. No action is needed at this time.

A nurse has assessed baseline fetal heart tones (FHTs) by auscultation and documents a funic souffle of 158 beats/minute and a uterine souffle of 90 beats/minute. When the first nurse gives a handoff report to an oncoming nurse, what can the second nurse conclude from this information? A. Fetal and maternal heart rates are outside of normal limits. B. Fetal and maternal heart rates are within normal limits. C. The second nurse cannot distinguish between fetal and maternal heart rates. D. There is a great deal of fetal heart rate variability between contractions.

B ~ Fetal heart tones (funic souffl) should be in the range of 110 to 160 beats/minute, so FHTs are within normal limits. The maternal heart rate (uterine souffl) is also within normal limits.

A woman is in the early latent phase of labor and is frustrated by the length of time this stage is taking. What action by the nurse is best? A. Administer 100% oxygen by face mask. B. Encourage frequent position changes or walking. C. Have the woman rest between contractions. D. Place the woman in a left side-lying position.

B ~ Frequent position changes and walking are beneficial in helping to promote the descent of the fetus during labor. The nurse should encourage the woman to try several positions (squatting, leaning over a piece of furniture, hands and knees position) and walking to try to enhance the progression of her labor. The other actions are not warranted.

A womans birthing plan includes completing the latent phase of the first stage of labor at home. When should the nurse teach the woman to come in to the birthing unit? A. After 10 hours of mild contractions B. When contractions are 3 to 5 minutes apart C. When contractions are experienced in the back D. When strong contractions occur 2 to 3 minutes apart

B ~ The latent phase of labor is often completed at home and includes contractions that feel like menstrual cramping accompanied by low back pain. During this phase, contractions are typically 5 minutes apart, last 30 to 45 seconds, and are considered mild. This phase of labor can last up to 14 hours. However, it is not the length of time in the phase but rather the characteristics of the contractions that would signal to the woman that she is entering the active phase of labor. Strong contractions that occur 2 to 3 minutes apart indicate the transition phase of labor.

A nurse assessing fetal heart tones hears them best below the level of the maternal umbilicus. What type of fetal presentation would this nurse expect? A. Breech B. Cephalic C. Footling D. Shoulder

B ~ Typically with a cephalic presentation, fetal heart tones will be heard best below the level of the maternal umbilicus.

A young girl in active labor arrives at the hospital without having had any prenatal care. She is extremely anxious and crying out in pain. What would the nurse assess to best determine that goals for the diagnosis of knowledge deficit have been met? (Select all that apply.) A. Begs her mother to stay with her while giving birth B. Can describe expected labor progress and states she is in less pain C. Is able to cooperate with breathing instructions during contractions D. Is able to give a history of this pregnancy to the admitting nurse E. States that after this birth, she wants to learn about birth control

B, C ~ A lack of knowledge can lead to anxiety and increased perceived pain. When the patient understands labor progression and the events surrounding childbirth, she will be better able to cooperate with breathing instructions and hopefully will feel less pain as she feels more in control. The other actions do not show the benefit of an educated patient.

The perinatal nurse describes normal maternal signs and symptoms associated with lightening to the prenatal class attendants. These signs and symptoms include which of the following? (Select all that apply.) A. Difficulty breathing B. Increased urinary frequency C. Increased vaginal secretions D. Leg cramps E. Nausea and vomiting

B, C, D ~ The downward settling that occurs during lightening may also lead to the following maternal symptoms: leg cramps or pains, increased pelvic pressure, increased urinary frequency, increased venous stasis that may cause edema in the lower extremities, and increased vaginal secretions related to congestion in the vaginal mucosa. The downward movement of the fetus actually may make breathing easier. Nausea and vomiting are not associated symptoms.

The perinatal nurse describes prelabor or Braxton Hicks contractions to the prenatal class attendants as which of the following? (Select all that apply.) A. Contributing to cervical effacement and dilation B. Felt in the abdomen or groin C. Intensely painful D. Irregular E. Regular and progressive

B, D ~ As the pregnancy approaches term, most women become more aware of irregular contractions called Braxton Hicks contractions. As the contractions increase in frequency (they may occur as often as every 10 to 20 minutes), they may be associated with increased discomfort. Braxton Hicks contractions are usually felt in the abdomen or groin region, and patients may mistake them for true labor. It is believed that these contractions contribute to the preparation of the cervix and uterus for the advent of true labor. However, Braxton Hicks contractions do not lead to dilation or effacement of the cervix, and therefore are often termed false labor.

A nulliparous woman in labor is 3 cm dilated at 10:00 a.m. Based on knowledge of the average nulliparous womans progression, when would the nurse expect her to be fully dilated? A. 12:00 p.m. B. 2:00 p.m. C. 5:00 p.m. D. 10:00 p.m.

C ~ A nulliparous woman, on average, dilates 1 cm/hour of labor. The nurse would expect this woman to be fully dilated 7 hours from the initial assessment, or at 5:00 p.m.

A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart rate increased during a contraction from 140 to 158. What action by the nurse preceptor is best? A. Gather equipment for internal FHT monitoring. B. Have the nurse document FHT of 140/158. C. Instruct the nurse to assess FHT between contractions. D. Tell the nurse to count only for 30 seconds.

C ~ Baseline fetal heart tones can only be assessed during the absence of uterine activity. The preceptor should instruct the new nurse to listen for FHTs between contractions. The woman does not need internal FHT monitoring based on this assessment. The reading is inaccurate, so the nurse preceptor should not have the new nurse document these findings and this method (140/158) is not appropriate. The new nurse may have to count fetal heart tones for only 30 seconds if the woman is having frequent contractions, although assessing for 1 minute is the most accurate method.

The OB nurse assesses moderate baseline variability on the fetal heart monitor. What action by the nurse is best? A. Administer a bolus of IV fluids. B. Discontinue oxytocin, if it is being delivered. C. Document the findings in the woman's chart. D. Perform fetal scalp or vibroacoustic stimulation.

C ~ Baseline variability is the most important predictor of adequate fetal oxygenation during labor. It can be described as absent, minimal, moderate, or marked. Adequate variability is described as moderate. This is a normal and reassuring finding and should be documented in the patients chart. No further action is needed.

A husband in the labor suite is concerned that as his wifes labor progresses, she has become distant, is not interested in conversation, and, at times, is short with him. Which response by the nurse is best? A. Don't worry; women often get this way during labor. B. Maybe if you step out for a while, she'll feel better. C. She must concentrate to cope with her labor. D. This is a difficult period; it will be over shortly.

C ~ During the active phase of labor, many women tend to draw inward in an attempt to cope with the increasing demands of the labor. The nurse should reassure the husband that this is a normal response. The first option does not give the husband any useful information. The woman needs her support person with her and the husband should not be sent away. The last option is dismissive.

A new nurse is caring for a woman in the transition phase of labor. The nurse attempts to engage the woman in conversation and chats even when the woman doesn't respond to these attempts. What action by the nurses preceptor is most appropriate? A. Direct the nurse to attempt conversation with the support person. B. Encourage the nurse to keep attempting to engage the woman in conversation. C. Gently ask the nurse to refrain from unnecessary conversation. D. Tell the nurse not to take the woman's silence as a personal rejection.

C ~ During the more intense phases of labor, women may draw inward in an attempt to cope with the increasing demands of their labor. Also, there are cultural differences in the way people respond to silence and conversation. Because this woman appears to be concentrating on her own body and labor and not responding to the nurse, the preceptor should gently ask the new nurse to refrain from all but necessary communication. This shows respect for the work the woman is doing. It is also a good idea to let the new nurse know that this is probably not a personal rejection, but it is more important to respect the woman's need for quiet.

The perinatal nurse knows that when the fetal head is fully extended and the occiput is near the spine, the delivery team should prepare for the presenting fetal part to be which of the following? A. Brow B. Chin C. Face D. Sacrum

C ~ In the face presentation, the fetal head is fully extended and the occiput is near the fetal spine. The submentobregmatic diameter presents to the maternal pelvis; the face is the presenting part.

A nurse assesses the fetal position in a laboring woman. The fetal position is documented as LSP. What action by the nurse is best? A. Continue to support the womans labor efforts. B. Document the findings in the womans chart. C. Inform the provider; prepare for possible cesarean delivery. D. Turn the woman on her left side; reassess in 30 minutes.

C ~ LSP indicates left, sacrum, posterior. This malpresentation may signal the need for a cesarean delivery. The nurse should not just support the woman's labor efforts, nor should the nurse document without taking other action. Turning the woman on her left side is not warranted.

During the second stage of labor, a nurse encourages effective pushing by the woman. What directions from the nurse best achieve this? A. Hold your breath and push as hard as you can. B. Now that you are fully dilated, start pushing. C. Push when you feel the urge and breathe between attempts. D. When you feel a contraction, push with your mouth closed.

C ~ Open-glottis pushing is the recommended technique of pushing during contractions. When the woman feels the urge to push, she is instructed to bear down while continuing to breathe between contractions. She is encouraged to only hold her breath for 5 to 6 seconds at a time so that air escapes during the pushing. This process facilitates maternal-fetal circulation and gradual fetal descent. The other instructions are not consistent with this method.

A patients cervix is 8 cm dilated and she is 100% effaced. What action by the nurse is most important at this time? A. Allow the support person to be at the bedside. B. Encourage the woman to bear down. C. Have the woman avoid pushing at this time. D. Instruct the woman to rest between contractions.

C ~ Pushing against a partially dilated cervix can lead to cervical edema and damage and can adversely affect the progress of the woman's labor. It is most important to protect the patient from injury. Encouraging rest between contractions and allowing the support person at the bedside are also important, but safety comes first.

A nurse reads in a womans chart that the fetus is in a longitudinal lie. What can the nurse conclude about this situation? A. The fetal head is flexed prior to delivery. B. The fetal head-to-tailbone axis is at a 90 angle to the womans head-to-tailbone axis. C. The fetal head-to-tailbone axis is the same as the womans head-to-tailbone axis. D. Vaginal birth will be very difficult.

C ~ The fetal lie is the relationship of the long axis of the woman to the long axis of the fetus. If the head-to-tailbone axis of the fetus is the same as the womans, the fetus is in a longitudinal lie. This occurs in more than 99% of pregnancies. Flexion of the fetal head is related to fetal attitude. When the long axis of the fetus is at a 90 angle to the long axis of the woman, it is called a transverse lie; this occurs in fewer than 1% of pregnancies.

A nurse is measuring the frequency of a laboring womans contractions. How does the nurse accomplish this correctly? A. Counts the number of contractions measured at the same intensity in 1 full minute B. Feels the fundus during the acme of the contraction and notes the fundal firmness C. Measures the beginning of one contraction to the beginning of the next contraction D. Measures the time from the beginning of one contraction to the end of the same contraction

C ~ The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction, not by counting contractions in 1 minute. Feeling the firmness of the fundus during contractions measures intensity. Measuring the time from the start of one contraction to the end of the same contraction measures duration.

The perinatal nurse describes different breech positions to the student nurse. The fetal position with extended legs toward the fetal shoulders is best described as which of the following? A. Complete breech B. Footling breech C. Frank breech D. Incomplete breech

C ~ There are three types of breech presentations: frank, complete, and footling. The frank breech is the most common of all breech presentations. In this position, the fetal legs are completely extended up toward the fetal shoulders. The hips are flexed, the knees are extended, and the fetal buttocks present first in the maternal pelvis. The complete, or full, breech position is the same as the frank breech position, except the knees are flexed and the legs crossed, with the fetal buttocks presenting first. In the footling breech position, one or both of the fetal leg(s) are extended, with one foot (single footling) or both feet (double footling) presenting first into the maternal pelvis.

A nurse is assessing a woman in labor. In order to assess the fetal position most accurately, which of the following methods should be used? A. Auscultation of fetal heart tones B. Leopold maneuvers C. Ultrasound examination D. Vaginal examination

C ~ Ultrasound is the most accurate way to assess the fetal position. Leopold maneuvers are not always accurate and may be clinically difficult, which also makes assessing fetal heart tones more difficult. A vaginal examination can be used, but if the membranes are still intact or if the cervix is only minimally dilated, the examiner may not be able to determine the fetus' position.

The faculty member teaching a class of students explains several theories regarding the onset of labor. Which of the following does the faculty member include? (Select all that apply.) A. Closure of ductus arteriosus B. Molding of the fetal head C. Placental aging D. Pressure on the cervix E. Uterine muscle stretching

C, D, E ~ Several theories regarding the onset of labor exist and include (among others) placental aging, pressure on the cervix, and uterine muscle stretching.

A nurse notes a perineal laceration that extends into the rectal mucosa after a woman gives birth to a full-term baby. How does the nurse document this information? A. First-degree laceration B. Second-degree laceration C. Third-degree laceration D. Fourth-degree laceration

D ~ A fourth-degree laceration extends into the rectal mucosa and exposes the lumen of the rectum. A first-degree laceration involves only the perineal skin and vaginal mucosa. A second-degree laceration involves the skin, mucous membrane, and fascia of the perineal body. A third-degree laceration involves the skin, mucous membrane, and muscle of the perineal body and extends into the rectal sphincter.

The nurse explains to the class of nursing students that umbilical cord clamping occurs at what time after birth? A. Immediately B. After 15 seconds C. After 30 to 60 seconds D. After 60 to 120 seconds

D ~ For the term infant, cord clamping should be delayed for 60 to 120 seconds (or until cord pulsation ceases). This provides the infant with more blood volume, red blood cells, and hematopoietic cells than when the cord is clamped immediately. The oxygen-rich blood traveling through the cord allows the neonate additional time to adjust to the outside world and a new way of breathing.

A nurse assessing a woman in labor notes late decelerations on the fetal monitor and documents contractions occurring every 1 to 2 minutes. Oxytocin (Pitocin) is being infused IV, and oxygen is being delivered at 8 L/min per mask. The woman is positioned on her left side. What action by the nurse takes priority? A. Discontinue the oxygen. B. Increase the oxytocin rate. C. Assist the woman to a supine position. D. Stop the oxytocin infusion.

D ~ Late decelerations are a sign of uteroplacental insufficiency and are often indicative of hypoxia and metabolic acidemia. Contractions that occur this frequently signify uterine hyperstimulation. Both circumstances indicate that the oxytocin should be stopped immediately. Discontinuing the oxygen and increasing the oxytocin infusion are both contraindicated. Placing the woman in a supine position can lead to maternal hypotension, worsening this situation.

The perinatal nurse assessing a laboring womans contraction intensity by internal monitoring would expect, during the transition phase, a reading in which of the following ranges? A. 10 to 12 mm Hg B. 20 to 40 mm Hg C. 50 to 70 mm Hg D. 70 to 90 mm Hg

D ~ One method to measure the intensity of uterine contractions is with the use of an internal monitor. If the amniotic membranes have ruptured, an internal pressure catheter is inserted through the cervix and into the uterus to measure the internal pressure generated during the contraction. Normally, the resting pressure in the uterus (between contractions) is 10 to 12 mm Hg. During the acme, contraction intensity ranges from 25 to 40 mm Hg during early labor, 50 to 70 mm Hg during active labor, 70 to 90 mm Hg during the transition phase, and 70 to 100 mm Hg during maternal pushing in the second stage.

The perinatal nurse is assessing a woman at 36 weeks gestation. Her fundal height measurement was last recorded at 34 cm. The patients abdomen appears to be widest from side to side. The nurse suspects the possibility of which type of fetal presentation? A. Breech B. Cephalic C. Face D. Shoulder

D ~ The fetal presentation may be cephalic, breech, or shoulder. The part of the fetal body first felt by the examining finger during a vaginal examination is the presenting part. The shoulder presentation is a transverse lie. This presentation is rare and occurs in less than 1% of births. When a transverse lie is present, the maternal abdomen appears large from side to side rather than up and down. The fetal head is palpated on one maternal side and the breech is palpated on the other side. Additionally, the woman may demonstrate a lower-than-expected fundal height measurement for gestational age.

A nurse suspects that a laboring woman has entered the second stage of labor by what assessment? A. Cervix is more than 50% dilated. B. Contractions are more frequent. C. Contractions are more intense. D. Woman has a strong urge to push.

D ~ The second stage of labor commences when the cervix is fully dilated and ends with the birth of the baby. The nurse (or woman) often suspects this has occurred when the woman has strong urges to push or has involuntary bearing-down efforts. Contractions remain similar to those experienced during transition.