chapter 15 1 and 2 Maternal
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."
The nurse is caring for a client who is a primigravida. Which statement is best to improve the client's psyche?
"You are doing a great job"
Which station is said to be floating
-4
the following are Signs of placental separation, SELECT ALL THAT APPLY.
-There is lengthening of the umbilical cord -The uterus becomes round in shapes contracts and feels firm again. -The placenta is visible at the vaginal opening. -A sudden gush of vaginal blood occurs.
which station means engaged
0
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 woman may spend time thinking about what is happening to her
describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other
Attitude
Which documentation in the health record is most correct for the third stage of labor?
Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.
The nurse is teaching a non-English speaking primigravida about the most common type of fetal presentation. Which presentation will the nurse prepare?
Cephalic presentation using preprinted materials in her language
Once separation has occurred, the placenta delivers either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by the primary healthcare provider
Crede's Maneuver
refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis.
Engagement
the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a woman's body
Fetal lie
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?
Head flexed forward so much that the chin touches the sternum
caused by the force of uterine contractions as the vertex of the head is pressed against the not yet dilated cervix. The overlapping that occurs in the sagittal suture line and, generally, the coronal suture line can be easily palpated on the newborn skull
Molding
A child is considered born when the head is born
Nothing. Normal time for stage three is 5 to 30 minutes.
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 frequency of the contractions is every 5 minutes.
The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?
The urge to push occurs.
Which action is a priority when caring for a woman during the fourth stage of labor?
assessing the uterine fundus
Such a position may occur in an otherwise healthy fetus or may be an indication there is less than the usual amount of amniotic fluid present (oligohydramnios), which is not allowing the fetus adequate movement space. It also may reflect a neurologic abnormality in the fetus causing spasticity.
complete extension
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, internal rotation, extension, external rotation, expulsion
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 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?
engagement
The body part of the fetus that has the widest diameter is the
head
Pregnant woman in labor is smiling and telling the nurse that she can't wait to meet her baby. What phase of stage 1 is the patient in?
latent
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.
when placenta separates in the center and folds in on itself as it descends into the lower part of uterus, the presentation is
maternal side (?)
the chin is not touching the chest but is in an alert or "military position"
moderate flexion
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?
occiput
A group of nursing students are preparing a presentation that will illustrate various components of the birthing process. When discussing the pelvis, the students should point out that the pelvis is often referred to as which term?
passageway
A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor?
second stage
smallest anteroposterior diameter
suboccipitobregmatic
During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs?
turn the patient onto the left side.
nuchal cord means
umbilical cord is encircling the neck
A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?
uterus becomes globular
during perineal cleaning, how many strokes are recommended by your maternal book?
6
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 sign is not an indication of starting labor?Untitled Question
constipation
A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?
contraction, regular and lasting longer and stronger
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?
crowning
How many cm from the base of umbilical cord should your place the cord clamp?
2
How many cm from the base of umbilical cord should your place the kelly forcep?
5