Chapter 13
A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated? "My 6-year old son will be in the birthing room, too." "I will remain in my bed for my labor and birth like last time." "I would like the baby's father to cut the umbilical cord." "We will hire a doula for our labor support."
"I will remain in my bed for my labor and birth like last time." -The nurse should educate the client that she will be encouraged to get out of bed during labor. In the labor and birth process, many positions, ambulation, and water therapy may be used for comfort and positioning. All other answers are appropriate client responses.
A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress? "There has been no further dilation (dilatation); effacement is progressing." Don't mention anything to the client yet; wait for further dilation (dilatation) to occur. "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."
"You are still 2 cm dilated, but the cervix is thinning out nicely." -Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilation (dilatation) but not effacement. Therefore, just saying, "no further dilation (dilatation)" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.
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? "Your cervix thins so that your contractions can increase." "Cervical thinning is a sign that you are in true labor." "It thins to let your baby change positions during labor." "You need the cervix to thin so it can stretch more easily."
"You need the cervix to thin so it can stretch more easily." -The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long the client will be in labor? "Your partner is in the active phase of labor, and birth will be within 2 to 3 hours, though it might be sooner." "Your partner is in active labor; they are progressing at this point and we will keep you posted." "Your partner is doing well and is in the second stage of labor; birth could be anytime now." "Your partner is still in early latent phase of labor; it is too early to estimate when they will give birth."
"Your partner is in active labor; they are progressing at this point and we will keep you posted." -At 7 cm dilated, the client is considered in the active phase of labor. There is no science that can predict the length of labor. The client is progressing in labor, and it is best that the nurse not give the family a specific time frame.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? -5 +4 +1 0
+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 -2 0 +4
-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.
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is: 1 cm above the ischial spines. 1 cm above the pubic bone. 1 cm below the pubic bone. 1 cm below the ischial spines.
1 cm above the ischial spines. -Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and referred to as a minus or plus, depending on its location above or below the ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spine, it is recorded as plus stations. Therefore this fetus is 1 cm above the ischial spines.
The nurse is assisting the health care provider with the pelvic assessment of a pregnant client. The nurse concludes that the obstetric conjugate will be how long if the distance between the symphysis pubis and sacral promontory is 13 cm? 15 cm 11 cm 13 cm 9 cm
11 cm -The obstetric conjugate measurement is the smallest diameter of the inlet through which the fetus must pass. This cannot be measured directly. This is determined by subtracting 1.5 cm to 2 cm from the diagonal conjugate, which extends from the symphysis pubis to the sacral promontory.
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel (fontanelle) will close. Which time span is the normal duration for the closure of the posterior fontanel (fontanelle)? 4 to 6 weeks 14 to 18 weeks 8 to 12 weeks 12 to 14 weeks
8 to 12 weeks -The posterior fontanel (fontanelle) is a triangular-shaped area at the back of the skull. The nurse should inform the client that the posterior fontanel (fontanelle) normally closes by 8 to 12 weeks after birth, and if there is delay the primary health care provider should be notified.
During which time is the nurse correct to document the end of the third stage of labor? When the mother is moved to the postpartum unit Following fetal birth When pushing begins At the time of placental delivery
At the time of placental delivery -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 documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Admission time and time of fetal birth Effacement time and time when contractions are regular Complete cervical dilation (dilatation) and time of fetal birth Time of mucus plug expulsion and full cervical dilation
Complete cervical dilation (dilatation) and time of fetal birth -The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
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? Cervix False pelvis Uterus Perineum
Cervix -The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
Which cardinal movement of delivery is the nurse correct to document by station? Extension Internal rotation Descent Flexion
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 Maternal request for pain medication Maternal heart rate and blood pressure The station in which the fetus is located
Fetal heart rate in relation to contractions -The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? Fetal presentation Fetal lie Fetal position Fetal attitude
Fetal lie -Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.
A multiparous woman at 39 weeks' gestation arrives at the labor and delivery unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix and 3 cm dilation. Which nursing action is best? Have the client ambulate in the hall and recheck. Send the client home and return if contractions increase Admit the client directly to the labor and delivery area Have the client rest in bed on her left side.
Have the client ambulate in the hall and recheck. -To determine if the client is in true labor, the nurse is most correct to have her walk in the hall for approximately an hour. At that point, the client is rechecked to identify if labor has progressed. If labor has progressed, the client is admitted. Having the client rest in bed is not helpful to assist in labor progression.
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. Prostaglandins Insulin Oxytocin Testosterone Thyroxine Progesterone
Prostaglandins Oxytocin Progesterone -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 cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
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 45° to that of client. Long axis of fetus is at 60° to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is perpendicular to that of client.
Long axis of fetus is perpendicular to that of client. -If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.
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? Transverse Oblique Obtuse Longitudinal
Longitudinal -The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie. In the transverse lie, the fetus lies crosswise to the maternal spine. An oblique lie is between the two. There is not an obtuse lie.
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? Vertex presentation Molding Caput succedaneum Cephalohematoma
Molding -The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? Nothing. Normal time for stage three is 5 to 30 minutes. Do a vaginal exam to see if the placenta is stuck in the birth canal. Increase the IV tocolytic to help in expulsion of the placenta. Notify the primary care provider of the problem.
Nothing. Normal time for stage three is 5 to 30 minutes. -Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.
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? Begin pushing as soon as the cervix has dilated to 8 cm. Hold the breath while pushing during contractions. Push with contractions and rest between them. Pant while pushing.
Push with contractions and rest between them. -Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.
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 ROP LOP LOA
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.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? Occurs in an irregular pattern Slows when the woman changes position Lasts about 20 to 25 seconds Radiates from the back to the front
Radiates from the back to the front -Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.
The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? Encourage women with previous cesareans to always have a cesarean. Reduce the rate of cesarean births among low-risk women. Ensure care during labor includes immunizations. Ensure all couples receive preconception genetic counseling.
Reduce the rate of cesarean births among low-risk women. -Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? The perineum is relaxing The cervix is softening The uterus is relaxing The cervix is dilating
The cervix is softening -The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? The client reports back pain, and the cervix is effacing and dilating. After walking for an hour, the contractions have not fully subsided. The contraction pains have been present for 5 hours, and the patterns are regular. The contraction pains are 2 minutes apart and 1 minute in duration.
The client reports back pain, and the cervix is effacing and dilating. -True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.
Which client outcome during the active phase labor is best? The client will state a pain level of 7 or less during contractions. The client will walk in the hall for 15 minutes every 2 hours. The client will tolerate 8 oz (240 ml) of clear liquids. The client will practice breathing techniques during contractions.
The client will practice breathing techniques during contractions. -The nurse identifies a priority during the active phase of labor as working with the contractions to give birth. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level will be less than 7 in the active phase. Walking in the hall and tolerating liquids also depends on the client.
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 floating high in the pelvis. The fetus is in the true pelvis and engaged. The client is fully effaced. The fetus has descended down the birth canal.
The fetus is in the true pelvis and engaged. -When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.
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 is in active labor. The duration of the contractions is every 5 minutes. The frequency of the contractions is every 5 minutes. The client can be sent home.
The frequency of the contractions is every 5 minutes. -Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions help in softening and ripening the cervix. These contractions make maternal breathing easier.
These contractions help in softening and ripening the cervix. -Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.
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 First Second Fourth
Third -Stage three begins with the birth of the baby and ends with delivery of the placenta.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of the frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? perineal phase pelvic phase latent phase active phase
active phase -The client is likely in the active phase of labor, which is in the first stage, as evidenced by the increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the active phase is 6 to 10 cm. The latent phase is in the first stage of labor and characterized by positive coping, mild contractions, and cervical dilation (dilatation) of 1 to 6 cm. The pelvic and perineal phases are in the second stage of labor. Contractions are every 2 to 3 minutes and the client is fully dilated (10 cm).
A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting? occiput acromion process chin buttocks
buttocks -The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.
A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lb (43 kg), and has gained 25 lb (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment? cannot be determined android platypelloid gynecoid
cannot be determined -Pelvis shape cannot be determined by the information included in the statement. The gynecoid is the most common; however, there is no way to predict it. Early in the pregnancy, particularly if a woman has never given birth to a baby vaginally, the practitioner may take pelvic measurements to estimate the size of the true pelvis. This helps to determine if the size is adequate for vaginal birth. However, these measurements do not consistently predict which women will have difficulty giving birth vaginally, so most practitioners allow the woman to labor and attempt a vaginal birth.
A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds? prostaglandins catecholamines relaxin oxytocin
catecholamines -Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur? bloody show lightening cervical ripening and softening Braxton Hicks contractions
cervical ripening and softening -The ripening and softening of the cervix that result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation (dilatation) of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucus plug is expelled as a result of cervical softening and increased pressure of the presenting part.
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? change in estrogen-to-progesterone ratio decrease in number of oxytocin receptors decrease in the level of estrogen decrease in prostaglandins, leading to myometrium contractions
change in estrogen-to-progesterone ratio -One of the theories suggests that labor is initiated by a change in the estrogen-to-progesterone ratio. The number of oxytocin receptors have been noted to increase. Estrogen levels also increase, which in turn increases myometrial sensitivity to oxytocin. Prostaglandin levels also increase, which in turn leads to myometrial contractions.
A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: extreme pressure in the vaginal vault. prolonged labor. cranial bones overlapping at the suture lines. a congenital defect.
cranial bones overlapping at the suture lines. -This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor.
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: descent, flexion, external rotation, extension, internal rotation, expulsion descent, flexion, internal rotation, extension, external rotation, expulsion internal rotation, descent, extension, flexion, external rotation, expulsion internal rotation, flexion, descent, extension, external rotation, expulsion
descent, flexion, internal rotation, extension, external rotation, expulsion -The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? start of regular contractions dilation (dilatation) of cervix diameter to 10 cm diffuse abdominal cramping rupturing of fetal membranes
dilation (dilatation) of cervix diameter to 10 cm -The first stage of labor terminates with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? intensity peak frequency duration
duration -Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.
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) effacement crowning molding
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 pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess? uterine abnormalities congenital anomalies birth after due date fetal anomalies
fetal anomalies -The nurse, along with the primary care provider, has to assess for fetal anomalies, which are usually associated with a shoulder presentation during a vaginal birth. The other conditions include placenta previa and multiple gestations. Uterine abnormalities, congenital anomalies, and prematurity are conditions associated with a breech presentation of the fetus during a vaginal birth.
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor? first, active second first, latent third
first, active -Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor, which is characterized by cervical dilation (dilatation) of 4 to 7 cm. Regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and at -1 station. The second stage of labor begins when the cervix is 10 cm dilated. The first latent phase is characterized by the onset of regular contractions and cervical dilation (dilatation) of 0 to 4 cm. The third stage of labor is from birth of the infant to completed delivery of the placenta.
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: frequency. peak. duration. intensity.
frequency. - Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? lying on side, arms grasped on abdomen squatting while holding her breath head elevated, grasping knees, breathing out lying supine with legs in lithotomy stirrups
head elevated, grasping knees, breathing out -For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).
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? cause discomfort over the top of uterus remain irregular with the same intensity increase even if relaxing and taking a shower subside when walking around and use the lateral position
increase even if relaxing and taking a shower -True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.
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 blood pressure increase in respiratory rate increase in gastric emptying and pH increase in heart rate slight decrease in body temperature
increase in blood pressure increase in respiratory rate increase in heart rate -When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in systolic blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? increased risk of infection potential rapid birth of fetus potential placenta previa increased risk of breech presentation
increased risk of infection -After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? increased blood glucose levels decreased plasma fibrinogen levels increased blood coagulation time increased white blood cell count
increased white blood cell count -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.
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? latent stage two stage three active
latent -The client in labor undergoes numerous psychologic adaptations during labor. During the latent phase, the client is often talkative and happy, and yet anxious. During active phase, the client may show fear and anger. Both the latent and active phases occur during stage 1. During stages 2 and, the client may remain positive, but the work of labor is very intense.
A nurse is caring for a 16-year-old primigravida client who is in active labor. The client did not attend prenatal classes and nervously asks the nurse to explain to what will happen. The nurse performs a focused assessment to determine the stage of labor and then explains the different phases of the first stage of labor. The nurse determines client understanding when they correctly identifies how each phase differs. -contractions 2 to 3 minutes apart strong to very strong -cervical dilation 4 to 7 cm -contractions 5 to 30 minutes apart -rapid dilation and effacement -contraction duration 45 to 90 seconds -contractions irregular, mild to moderate -start of fetal descent -contraction duration 30 to 45 seconds -complete dilation and effacement
latent -contractions irregular, mild to moderate -start of fetal descent -contraction duration 30 to 45 seconds active -cervical dilation 4 to 7 cm -contractions 2 to 3 minutes apart strong to very strong -contractions 5 to 30 minutes apart -rapid dilation and effacement -contraction duration 45 to 90 seconds -complete dilation and effacement -A pregnant client will progress through two phases during the first stage of labor: latent and active. The first phase of the first stage of labor is the latent phase, where the client is talkative. In this phase, contractions are irregular and mild to moderate, 5 to 30 minutes apart, and last 30 to 45 seconds. The second phase of the first stage labor is the active phase. In the beginning of this phase, contractions become more regular and moderate to strong, occur every 3 to 5 minutes, and last 40 to 70 seconds. There is also rapid cervical dilation 4 to 7 cm, and the fetus starts to descend. In the end of the active phase of the first stage of labor, the contractions become strong and occur 2 to 3 minutes apart, and last 45 to 90 seconds. At the end, complete cervical dilation at 10 cm with full effacement occurs.
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. constipation lightening weight gain bloody show backache
lightening bloody show backache -The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilation (dilatation). Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.
A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared? less likely to need analgesia unlikely to require cesarean birth less likely to need anesthesia need for someone to control the situation
need for someone to control the situation -Prenatal education teaches the woman about the birth experience and increases her sense of control. An increasing body of evidence indicates that the well-prepared woman, with good labor support, is less likely to need analgesia or anesthesia and is unlikely to require cesarean birth.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? buttocks shoulders occiput brow
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.
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? hypoxia of the contracting uterine muscles distention of the vagina and perineum pressure on the lower back, buttocks, and thighs pain from the dilation (dilatation) or stretching of the cervix
pain from the dilation (dilatation) or stretching of the cervix -In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.
The five "Ps" of labor are: passenger, position, powers, presentation, psych. passenger, position, presentation, pushing, psych. passageway, passenger, position, powers, psych. passenger, posture, position, presentation, psych.
passageway, passenger, position, powers, psych. -The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).
A nurse knows that a doula can be part of a laboring client's health care team. Which intervention would the nurse explain to the client is part of the doula's responsibility? monitoring intake and output and adjusting the IV maintenance line interpreting the fetal monitoring strips for fetal stability escorting the father/partner out of the room during the labor and birth providing support and explanations during labor and birth
providing support and explanations during labor and birth -A doula provides support, encouragement, comfort measures, and explanations of the process throughout labor and birth. The doula does not replace the partner/father or provide nursing tasks during the process.
The assessment of a pregnant client who is toward the end of her third trimester reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client? Select all that apply. hypotonic character of the bladder reduction in cervical resistance softening and thinning of the cervix boggy appearance of the uterus myometrial contractions
reduction in cervical resistance softening and thinning of the cervix myometrial contractions -Upon seeing the increased prostaglandin levels, the nurse should assess for myometrial contractions, leading to a reduction in cervical resistance and subsequent softening and thinning of the cervix. The uterus of the client will appear boggy during the fourth stage of labor, after the completion of pregnancy and birth. Hypotonic character of the bladder is also marked during the fourth stage of pregnancy, not when the prostaglandin levels rise, marking the onset of labor.
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? prolactin progesterone oxytocin relaxin
relaxin -As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.
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 buttocks are presenting first with both legs extended up toward the face. one leg is presenting. one arm is presenting. the fetus is sitting cross-legged above the cervix.
the buttocks are presenting first with both legs extended up toward the face. -In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? transition phase active phase early phase latent phase
transition phase -The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation (dilatation) of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.
