Chapter 13 PrepU
The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care? A. No nursing care is needed to be done during this time. B. A woman may spend time thinking about what is happening to her. C. A woman will rarely speak or laugh during this period. D. A woman should be left entirely alone during this period.
B. A woman may spend time thinking about what is happening to her Women need a support person with them during all stages of labor.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A. Shoulders B. Occiput C. Brow D. Buttocks
B. 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.
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? A. descent B. restitution C. engagement D. crowning
D. crowning Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.
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? A. dilation (dilatation) of cervix diameter to 10 cm B. diffuse abdominal cramping C. start of regular contractions D. rupturing of fetal membranes
A. 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.
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: A. start of labor. B. lightening. C. rupture of the membranes. D. placenta previa.
B. lightening. Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor. It is a premonitory sign of labor and is not associated with rupture of membranes or placental previa.
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? A. intensity B. peak C. frequency D. duration
D. 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.
Dilation (dilatation) follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement? A. 8 to 10 cm B. 3 to 4 cm C. 12 to 14 cm D. 7 to 8 cm
A. 8 to 10 cm Full dilation (dilatation) of the cervix is 8 to 10 cm.
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? A. decrease in arterial carbon dioxide pressure B. increase in fetal breathing movements C. increase in fetal oxygen pressure D. decrease in circulation and perfusion to the fetus
D. decrease in circulation and perfusion to the fetus When monitoring fetal responses in a client experiencing labor, the nurse should monitor for a decrease in circulation and perfusion to the fetus secondary to uterine contractions. The nurse should monitor for an increase, not a decrease, in arterial carbon dioxide pressure. The nurse should also monitor for a decrease, not an increase, in fetal breathing movements throughout labor. The nurse should monitor for a decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen.
Which cardinal movement of delivery is the nurse correct to document by station? A. Extension B. Flexion C. Internal rotation D. Descent
D. 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.
A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? A. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks" B. "This is not normal unless you are in active labor; come to the hospital and be checked" C. "That is something we expect with a second or third baby, but because it is your first, you need to be checked" D. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital"
A. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks" The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? A. 5 to 7 B. 0 to 2 C. 3 to 4 D. 8 to 10
D. 8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation (dilatation) would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? A. Time of mucus plug expulsion and full cervical dilation B. Effacement time and time when contractions are regular C. Complete cervical dilation (dilatation) and time of fetal birth D. Admission time and time of fetal birth
C. 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.
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? A. "This is just a way of determining your progress in labor" B. "This indicates that you start labor within the next 24 hours" C. "This means +1 and the baby is entering the true pelvis" D. "The presenting part is at the true pelvis and is engaged"
D. "The presenting part is at the true pelvis and is engaged" 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? A. +1 B. -5 C. 0 D. +4
D. +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 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? A. Give the medication as an IM injection using the Z-track technique B. Administer the medication piggybacked into a primary IV line using a pump C. Give the medication orally every hour for the first 4 hours D. Assist with insertion of a central venous access device for administration
B. Administer the medication piggybacked into a primary IV line using a pump Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It is not given orally, via IM injection, or through a central venous access device.
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? A. flexion B. engagement C. expulsion D. extension
B. engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most? A. just to be left alone B. intense nursing care C. positive reinforcement D. their significant other beside them
C. positive reinforcement Any woman, even one who has taken natural childbirth classes, has a difficult time maintaining positive coping strategies during this phase of labor. Many women describe feeling out of control during this phase of labor. A woman in transition needs support, encouragement, and positive reinforcement.
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? A. uterine abnormalities B. fetal anomalies C. congenital anomalies D. birth after due date
B. 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 primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? A. Tell the woman to stay home until her membranes rupture. B. Emphasize that food and fluid should stop or be light. C. Ask the woman to describe why she believes that she is in labor. D. Arrange for the woman to come to the hospital for labor evaluation.
C. Ask the woman to describe why she believes that she is in labor. The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not she is in labor. The client may be in false labor, and more information should be obtained before she is brought to the hospital.
The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? A. wrapping of the head B. developmental delay C. a cephalohematoma D. a caput succedaneum
C. a cephalohematoma Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. Instructions for care include simple observation of the area. The cephalohematoma will subside in a couple of weeks and may take a couple of months to completely go away. There is no brain damage associated with a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.
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: A. duration B. intensity C. frequency D. peak
C. 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.
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? A. "My 6-year-old son will be in the birthing room, too" B. "I would like the baby's father to cut the umbilical cord" C. "We will hire a doula for our labor support" D. "I will remain in my bed for my labor and birth like last time"
D. "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.
Which cardinal movement allows the fetus to travel through the birth canal most efficiently? A. External rotation B. Engagement C. Extension D. Flexion
D. Flexion As the fetus progresses down the birth canal, flexion coaxes the fetus to assume the position of the smallest diameter of the fetal head to fit through the dimension of the pelvis. Extension and external rotation occur later in the labor process before birth and passes the fetal head through the pubic arch to birth of the head. Engagement occurs when the fetal head descends to the level of the ischial spines and can occur 2 weeks prior to the initiation of labor.
A fetus is assessed at 2cm above the ischial spines. How would the nurse document the fetal station? A. +4 B. +2 C. 0 D. -2
D. -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.
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? A. third B. first, latent C. first, active D. second
C. 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.
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? A. crowning B. molding C. dilation (dilatation) D. effacement
D. 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 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? A. "The contractions lessen after I drink a large glass of water." B. "I feel pressure in my vagina when I have the contraction." C. "I will have a strong one and then the next one will be weaker." D. "I feel the tightening primarily in the front of my belly."
B. "I feel pressure in my vagina when I have the contraction." True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.
