Quiz: Chapter 19, Nursing Care of the Family During Labor and Birth

Which statement indicates effective learning regarding the manifestations of true labor?

"Contractions become more intense with walking."

Which type of vaginal discharge is more common during the transition phase of the first stage of labor?

Bloody mucus During the transition phase, the cervix is dilated to 8 to 10 cm, which results in the appearance of bloody mucus in the vaginal discharge. Pale pink mucus is seen in the latent phase, in which the cervix dilates to not more than 3 cm. Brownish discharge may also be observed during the latent phase of the first stage of labor. Pink-to-bloody mucus is observed in the active phase of cervical dilation.

Which principle guides the nurse when performing a vaginal examination on laboring clients?

Cleanse the vulva and perineum before and after the examination as needed

Which characteristic is associated with false labor contractions?

Decrease in intensity with ambulation

Which evidence-based practice supports normal labor and birth during the immediate newborn period?

Encouraging skin-to-skin contact of the mother and baby

Which supportive care measure is appropriate for a client complaining of back labor pain?

Lean over a birth ball with her knees on the floor

Which condition is occurring in a multiparous client who has just given birth, her fundus is firm and globular, and she has a gush of dark red blood from her vagina?

The placenta has separated

Which client behavior is expected during the transition phase of the first stage of labor?

Vomits

Which nursing instruction would reduce the risk of urinary retention in a client during labor?

"I can show you some techniques to help stimulate voiding

Which nursing instruction would ensure fetal safety during the second stage of labor?

"Push when you feel the urge.

During which period would the health care provider perform an episiotomy for a client who is expected to deliver a newborn who is large for gestational age (LGA)?

During crowning

Which client finding indicates a potential risk for complications during the labor process?

Persistent dark red vaginal bleeding

Which laboratory finding in a client's urinalysis report indicates preeclampsia?

Proteins

Which is a part of the role of doula care for a laboring client? Select all that apply.

Providing comfort measures Providing support to the client's partner Providing coaching during the second stage of labor

Which position facilitates the pelvic outlet to increase in second-stage labor?

Squatting Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. A semirecumbent position would not assist in increasing the size of the pelvic outlet. Although sitting may assist with fetal descent, this position would not increase the size of the pelvic outlet. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet.

Which statement by the nurse describes the type of questions that help distinguish if a client is experiencing true labor? Select all that apply.

Where are you feeling your contractions?" "Have your contractions become closer together?" "Do your contractions feel the same when you are lying down?"

Which statement describes the nursing instructions for a client in the second stage of labor with an epidural?

"Take a deep breath in, and let your breath out slowly while pushing down. The active pushing phase occurs in the second stage of labor. The client would be instructed to use spontaneous open-glottis pushing to promote fetal oxygenation during this phase. Therefore, the client would be instructed to exhale while bearing down for 6 to 8 seconds at a time, followed by a cleansing breath. The Valsalva maneuver occurs during closed glottis pushing. Closed glottis pushing can be described as taking a deep breath and bearing down; this type of pushing reduces the cardiac output and decreases perfusion to the uterus and placenta, adversely affecting the fetus. It is essential to encourage the client to push during contractions in the second stage of labor, especially if the client with an epidural is not aware of her contractions. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each choice will seem like the correct response.

Which nursing intervention is performed to reduce the extent of vaginal or perineal lacerations?

Applying gentle pressure toward the client's vagina

Which interventions would promote safety when assisting a client in labor with showering? Select all that apply.

Assess for progress in labor Supervise showers during true labor. A warm shower may help relieve discomfort in a client who is in labor. Before the client showers, the nurse would first assess her progress in labor to determine if she is close to delivery. The nurse would supervise the client during the shower to prevent a fall. Pouring warm water over the client's vulva or placing her hand in warm water during a shower may not promote safety; these interventions may help the client urinate. Assisting the client in oral hygiene may promote oral health but may not be helpful in promoting safety.

Which immediate nursing intervention is provided after reviewing the physical assessment data of a client in the fourth stage of labor?

Assist the client to void spontaneously. A palpable and distended bladder may indicate urinary retention. A distended bladder may lead to fundal atony, increasing the risk of postpartum hemorrhage and bleeding. Perineal pain and drainage is common during the postpartum period. The nurse would encourage the client to void spontaneously to help the bladder return to its nonpalpable stage; it also helps increase the tone of the uterine fundus and makes it firm. Massaging the abdomen helps the uterus to contract. Cleansing the perineum using warm water would reduce the client's discomfort and relieve perineal pain. Cleansing vaginal lacerations is not an appropriate intervention because there are no lacerations reported in this client's data. The nurse would assist the client to flex her upper leg on the hip to observe vaginal lacerations, and using warm water is preferred to hot water.

Which clinical findings are associated with the early phase of labor for a nulliparous client who is 2 cm dilated? Select all that apply.

Client takes direction easily Scant amount of vaginal discharge Presence of mild to moderate contractions A nulliparous client who is 2 cm dilated in the early phase of labor would take direction easily, experience a scant amount of vaginal discharge, and have mild to moderate contractions. The fetal station would not necessarily be zero; however, this finding can be expected with cervical dilation from 6 cm. Bloody mucus is an expected finding for a client at 6 to 10 cm.

Which is characteristic of true labor contractions?

Continues and gets stronger, even if the client relaxes and takes a shower True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically, the contractions often stop with walking or a change of position.

Which are signs of potential complications of labor? Select all that apply.

Contractions lasting 90 seconds or longer Irregular fetal heart rate (FHR); suspected fetal arrhythmias More than five contractions in a 5-minute period Relaxation between contractions lasting shorter than 30 seconds Intrauterine pressure of ≥80 mm Hg or resting tone of ≥20 mm Hg (both determined by internal monitoring with intrauterine pressure catheter [IUPC]

Arrange the steps in the appropriate order for conducting a nitrazine pH test.

Correct 1.Inform the client and partner about the procedure. Correct 2.Soak the cotton-tipped applicator in nitrazine dye. Correct 3.Insert the cotton-tipped applicator deep into the vagina. Correct 4.Perform perineal care for the client as required. Correct 5.Document the test result in the client record A nitrazine dye test is performed to learn the status of the amniotic membrane in the pregnant client. Informing the client and her partner about the procedure makes the client feel comfortable. The cotton-tipped applicator specified for this procedure is soaked in nitrazine dye. Then the applicator is inserted into the vagina to get the fluid on the applicator. Perineal care is then performed to ensure that there is no risk of infection. Finally, the test result is seen and documented appropriately.

Which description of the phases of the second stage of labor is accurate?

Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or "laboring down," period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

Which nursing action would be taken immediately following the vaginal birth of a healthy term newborn?

Drying the infant on the mother's chest and then placing a hat on the infant After the birth of a healthy term newborn, the nurse would place the infant prone on the mother's chest, dry the neonate, and then place the hat. The hat is placed after the infant's head is dried. There is no indication that the infant would be taken to a warmer; it is recommended that the infant be placed skin to skin. The wet blankets are removed after the infant is dried and a hat is placed.

Which measures enhance the progress of fetal descent when managing the care of a client in the second stage of labor?

Encouraging the client to try various upright positions, including squatting and standing

Which nursing intervention is useful for a client in labor to reduce intrathoracic pressure and prevent fetal hypoxia?

Exhale, holding her breath for short periods

Which testing for ruptured membranes is appropriate for a client at 39 weeks of gestation who presents to labor and delivery concerned that she has ruptured amniotic membranes?

Ferning

Which would the nurse be prepared to record before the health care provider artificially ruptures a laboring client's membranes?

Fetal heart rate

Which parameter is closely monitored in a client during the latent phase of the first stage of labor?

Fetal heart rate During the first stage of labor, uterine contractions have just begun and the fetus is monitored for various parameters. The fetal heart rate is monitored at least every 30 to 60 minutes to ensure the safety of the fetus. Cervical dilation is assessed through vaginal examination and helps determine the approximate time required for delivery. Maternal temperature is monitored every 2 to 4 hours to ensure the client's safety. External cephalic version is performed to align the fetus to the birth canal.

Which assessment findings are obtained while performing Leopold's maneuver in a client who is in the first stage of labor? Select all that apply.

Fetal part in the fundus Presenting part of the fetus Descent of the fetus into the pelvis Leopold maneuvers, or abdominal palpation, during first stage of labor help determine the fetal part present in the fundus, which indicates the fetal lie. The presenting part of the fetus would help determine if the client would undergo vaginal birth or require a cesarean delivery. The position and location of the fetal back helps determine the descent of the fetus into the pelvis, which indicates the approximate time required for vaginal delivery. The fetal heart rate can only be auscultated using Doppler ultrasonography. However, using abdominal palpation, the point of maximum intensity of the fetal heart rate can be determined. The nurse may not assess the tone of the fundus during the first stage of labor; this is done after delivery of the infant to determine the risk of postpartum hemorrhage.

Which degree of severity is indicated for a client's perineal laceration involving the anterior rectal wall during childbirth?

Fourth degree Perineal lacerations usually occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. Lacerations that also involve the anterior rectal wall are classified as fourth degree. Lacerations that extend through the skin and the structures superficial to muscles are classified as first degree. Lacerations that extend through the muscles of the perineal body are classified as second degree. Lacerations that continue through the anal sphincter muscle are classified as third degree.

Which position would the nurse identify as effective in facilitating the rotation of a fetus from a posterior occipital to an anterior occipital presentation?

Hands and knees

Which clinical signs are associated with the placenta separating from the uterine wall after birth? Select all that apply.

Increased vaginal bleeding Presence of fetal membranes at the introitus Change in contour of the uterus Clinical signs associated with separation of the placenta from the uterine wall are increased vaginal bleeding (or a "gush" of bleeding), a change in the contour of the uterus from discoid to globular ovoid shape, and presence of fetal membranes at the introitus. The umbilical cord would lengthen, and uterine contractions would not increase, but the fundus would be firmly contracted.

Which are characteristics of the fourth stage of labor? Select all that apply.

It is a crucial time for the mother and newborn. Includes the first 1 to 2 hours after birth. During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. The mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members The fourth stage of labor is a crucial time for the mother and the newborn; it includes the first 1 to 2 hours after birth. During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. The mother and baby are not only recovering from the physical process of birth, but are also becoming acquainted with each other and additional family members. The second (not fourth) stage of labor is delivery of the fetus. The third (not fourth) stage of labor includes delivery of the placenta.

Which nursing response is appropriate for a client who is 39 weeks pregnant and expresses concern about her impending labor and how she will manage?

It's normal to be anxious about labor. Let's discuss what makes you afraid

Which intervention ensures the safety of the mother and the fetus during the birthing process?

Monitor the client's emotional and physiologic responses

Which circumstances would warrant the nurse to perform a vaginal examination? Select all that apply.

On admission to the hospital at the start of labor On maternal perception of perineal pressure or the urge to bear down When rupture of membranes (ROM) occurs A vaginal examination would be performed when the client is admitted to the hospital or birthing center at the start of labor. When the client perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After ROM, a vaginal examination would be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. The nurse would never perform a vaginal examination if vaginal bleeding is present because the bleeding could be a sign of placenta previa, and a vaginal examination could result in further separation of the low-lying placenta.

Which are characteristics of the second stage of labor? Select all that apply.

The second stage of labor is the stage in which the infant is born. This stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of this stage of labor is 50 to 60 minutes in nulliparous clients and 20 to 30 minutes in multiparous clients. During the second stage of labor, the infant is born; this stage begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates achievement of the expected outcome of a spontaneous, uncomplicated vaginal birth. The median duration of second-stage labor is 50 to 60 minutes in nulliparous clients and 20 to 30 minutes in multiparous clients. In the first stage of labor, the birthing table is usually not set up for the nulliparous client, and the progress of labor is enhanced when a client changes her position frequently.

Which rationales explain the nursing intervention of placing both hands, one over the other, on the client's abdomen and applying downward pressure toward the vagina? Select all that apply.

To determine whether the fundus is firm To assist the client in expelling clots

Which client behavior is expected during the transition phase of the first stage of labor? 1

Vomits A client in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The client may hyperventilate, resulting in nausea and vomiting. The client may remain calm and silent in the latent phase of uterine contractions, because the urge to bear down is not too strong in this phase. During the active stage of labor, the client may become doubtful of her ability to control pain. The client's attention is directed inward in the active phase of the first stage of labor.

Which type of laceration is expected in a client who has suffered perineal tears?

vaginal