1320 PREP U ch 8 the labor process

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?

"The contractions slow down when I walk around." False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

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?

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

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

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement?

"I feel pressure in my vagina when I have the contraction."

During a visit to the prenatal clinic, a pregnant woman asks the nurse, "What causes labor to start?" Which response by the nurse would be appropriate?

"Labor starts from a combination of several maternal and fetal hormones working together."

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?

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

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate?

"You need the cervix to thin so it can stretch more easily."

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 As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2 When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A fetus at 0 (zero) station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.

During the fourth stage of labor, which mother typically experiences the strongest afterpains?

A multipara who is breastfeeding Afterpains are variable contractions that occur after the birth of the newborn and delivery of the placenta. These afterpains occur in the recovery phase. In general, afterpains are more noticeable for the multiparous woman.

At which point along the birth canal must the fetal head extend for successful passage?

At the level of the symphysis pubis

During which time is the nurse correct to document the end of the third stage of labor?

At the time of placental delivery

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

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 Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

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

Fetal lie

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

Have a blue bulb suction and an infant warmer ready.

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?

Is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?

Longitudinal

After pelvic measurements, a patient who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this?

Passageway Passageway focuses on the size and contour of the pregnant patient's pelvis. Passenger addresses the size, position, and presentation of the fetus. Powers determine if uterine factors for labor are adequate. Psychological outlook focuses on the pregnant patient's ability to view labor as a positive experience.

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?

Significant head molding

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?

Take no extra measures; prepare for a standard labor.

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions.

The nurse is teaching a pregnant patient the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor?

The fetal head bends forward onto the chest.

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 is in the true pelvis and engaged.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

allowing the woman time to be alone

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?

degree of thinning

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?

effacement The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?

frank

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted?

gynecoid

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:

latent phase of the first stage.

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.

strong desire to push irritability with restlessness

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?

lie The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.

A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why." Which response by the nurse would be most appropriate?

"You had a burst of epinephrine, which is common before labor." Some women report a sudden increase in energy before labor. This is sometimes referred to as nesting because many women will focus this energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household. The increased energy level usually occurs 24 to 48 hours before the onset of labor. It is thought to be the result of an increase in epinephrine (adrenaline) release caused by a decrease in progesterone. The burst of energy is unrelated to getting everything ready, the mind telling the woman that she will be going into labor, or looking forward to the birth.

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

Molding

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document?

completion of the third stage of labor

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom?

moderately strong contractions every 4 minutes, lasting about 1 minute

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

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

Hemorrhage During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.