The Labor Process
A primagravida has an office appointment in her 39th week of pregnancy. Which assessment data is most definitive of the onset of labor? -The mother reports frequent urination. -The fetal head is engaged in the pelvis. -Cervical ripening is noted on examination. -Expulsion of the mucous plug.
Cervical ripening is noted on examination. Explanation: Clinical signs that labor is approaching include ripening or softening of the cervix with effacement and dilation. Frequent urination is common during engagement where the fetal head is in the pelvis. This is common up to 2 weeks before true labor begins. Expulsion of the mucous plug also is common a week or two before labor begins
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? -False pelvis -Cervix -Perineum -Uterus
Cervix Explanation: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
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. -Testosterone -Oxytocin -Thyroxin -Progesterone -Prostaglandins -Insulin
Oxytocin Progesterone Prostaglandins Explanation: There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins causes the cervix to soften and also causes the uterus to contract. Testosterone, thyroxin and insulin are not one of the main factors in the onset of labor theories.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? -The client's cervix is fully dilated. -The infant is born. -The client has contractions once every two minutes. -The client experiences her first full contraction.
The client's cervix is fully dilated. Explanation: The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage
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? -First -Second -Third -Fourth
Third Explanation: Stage three begins with the birth of the baby and ends with delivery of the placenta
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? -decreased plasma fibrinogen levels -increased blood coagulation time -increased blood glucose levels -increased white blood cell count
increased white blood cell count Explanation: The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.
When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche? -"The labor process is typically shorter for subsequent pregnancies." -"You can have input into the labor plan as you know what to expect." -"The intensity of contractions are much greater throughout the labor." -"You had a successful labor and vaginal delivery with your first pregnancy."
"You had a successful labor and vaginal delivery with your first pregnancy." Explanation: Reminding the client of her successful labor and birth best provides confidence, which strengthens a woman's psyche. It is true that subsequent pregnancies are typically shorter in length, and input in the labor plan by the multipara client can be expressed (since the woman has already experienced the process), but these are not as important as successfully completing the process. Depending upon the client's past experiences, the intensity of the contractions may or may not be more intense.
A nurse is conducting an in-service program for a group of nurses working in the prenatal clinic. When discussing the theories about the onset of labor, the nurse points out which factor as a possible cause? Select all that apply. -increase in the production of progesterone -fall in the estrogen at 34 to 35 weeks of pregnancy -decrease in the fetal cortisol levels -release of oxytocin by the pituitary -prostaglandin production in the myometrium
-release of oxytocin by the pituitary -prostaglandin production in the myometrium Explanation: The possible causes for the onset of labor include an increase in the fetal cortisol levels, release of oxytocin by the posterior pituitary, and the production of prostaglandins. Progesterone withdrawal, and not an increase, initiates labor. There is a rise in the estrogen levels at 34 to 35 weeks of pregnancy. Estrogen stimulates prostaglandin production and also promotes the release of oxytocin.
When measuring the diagonal conjugate of a woman's pelvis, the distance between which of the following anatomic landmarks would be used? -Anterior surface of the sacral prominence and the anterior surface of the symphysis pubis -Medial surface of the ischial tuberosities -Interior surface of the sacral prominence and the posterior surface of the symphysis pubis -Posterior surface of sacrum and the axis of the ischial tuberosities
Anterior surface of the sacral prominence and the anterior surface of the symphysis pubis Explanation: The diagonal conjugate measures the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis, or the anterior-posterior diameter of the pelvic inlet.
At which point along the birth canal must the fetal head extend for successful passage? -At the level of the iliac crest -At the level of the symphysis pubis -At the level of the ischial spines -At the level of the pelvic inlet
At the level of the symphysis pubis Explanation: Fetal extension occurs late in the labor process as the fetus extends through the final portion of the passageway. The fetal head must extend at the symphysis pubis for successful passage. The next step is the head being born. The pelvic inlet, iliac crest and ischial spines are high in the birth canal.
During which time is the nurse correct to document the end of the third stage of labor? -Following fetal birth -When pushing begins -At the time of placental delivery -When the mother is moved to the postpartum unit
At the time of placental delivery Explanation: The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.
The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize? -The client's vital signs -The end of recovery -The completion of the third stage of labor -The transition phase
The completion of the third stage of labor Explanation: The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The client's vital signs should be monitored throughout the entire process but are not the priority with the expulsion of the placenta.
"Vaginal birth of a live male in the vertex presentation, ROA position." The following nursing note was documented in the client's record by the labor room nurse. In which postion was the client born? -With the occiput facing the right anterior quadrant of the pelvis -Rear facing with the occiput facing the posterior quadrant of the pelvis -With the right side presenting, and the occiput facing the anterior quadrant -With the brow facing the right anterior quadrant of the pelvis
With the occiput facing the right anterior quadrant of the pelvis Explanation: A fetus in the vertex presentation has the occiput as the reference point. If the occiput is facing the anterior quadrant of the pelvis, the nurse is correct to record the position as ROA. Proper notation does not include a rear or right facing position. The vertex presentation is associated with the fetal occiput, not brow.
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? -regular contractions -cervical dilation -fetal movement through the birth canal -placental separation
cervical dilation Explanation: The primary change occurring during the first stage of labor is progressive cervical dilation. Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.
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? -relationship of the presenting part to the maternal pelvis -part of the fetal body entering the maternal pelvis first -relation of the fetal presenting part to the maternal ischial spine -relation of the different fetal body parts to one another
part of the fetal body entering the maternal pelvis first Explanation: The term presentation is the part of the fetal body that is entering the maternal pelvis first. Relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. Relation of the fetal presenting part to maternal ischial spine is termed the station.
A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? Select all that apply. -cervical dilation of 6 cm -cervical effacement of 70% -strong desire to push -apprehension mixed with excitement -irritability with restlessness
strong desire to push irritability with restlessness Explanation: A strong desire to push occurs most often in the transition phase of the first stage of labor. During this phase the woman commonly experiences increased apprehension and irritability with restless movements and feelings of loss of control and being overwhelmed. Cervical dilation from 4 to 7 cm characterizes the active phase of the first stage of labor. The woman in the early or latent phase of the first stage of labor often is filled with apprehension but is excited about the start of labor. During the active phase of the first stage of labor, cervical effacement of 40% to 80% occurs.
A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: -latent phase of the first stage of labor. -active phase of the first stage of labor. -transition phase of the first stage of labor. -pelvic phase of the second stage of labor.
transition phase of the first stage of labor. Explanation: The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The active phase is characterized by moderate to strong contractions every 2 to 5 minutes, cervical dilation of 4 to 7 cm and effacement of 40% to 80%, with the mother becoming intense and inwardly focused. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.