Chpater 13 PrepU
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? lying supine with legs in lithotomy stirrups squatting while holding her breath head elevated, grasping knees, breathing out lying on side, arms grasped on abdomen
Correct response: head elevated, grasping knees, breathing out Explanation: An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.
effacement
Shortening and thinning of the cervix
The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding? 0% effaced. 50% effaced. 75% effaced. 100% effaced.
Correct response: 50% effaced. Explanation: A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 0.5 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? cephalic vertex breech shoulder
Correct response: shoulder Explanation: The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.
The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor? The infant needs to be assessed by the health care provider. Ecchymosis indicates a blood disorder and the infant will need testing. Ecchymosis with edema on the scalp is where the infant was pushed out of the canal. Edema is swelling and caused by unusual trauma; the provider must have used forceps.
Correct response: Ecchymosis with edema on the scalp is where the infant was pushed out of the canal. Explanation: Ecchymosis and edema are normal findings when located on the part that was presenting in labor. The infant was ROA, so the head was the presenting part and has normal bruising and swelling. The effects of birth are normal, and are not of concern. Communicate to the parents that it is similar to a bruise or a blister. This sign is not indicative of the use of forceps.
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. the fetus is sitting cross-legged above the cervix. one leg is presenting. one arm is presenting.
Correct response: the buttocks are presenting first with both legs extended up toward the face. Explanation: 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.
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 Caput succedaneum Cephalohematoma Vertex presentation
Correct response: Molding Explanation: 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.
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? effacement and dilation of the cervix shortening of the upper uterine segment reduction in length of the cervical canal restoration of blood flow to uterus and placenta
Correct response: restoration of blood flow to uterus and placenta Explanation: The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation of the cervix are other processes that occur during uterine contractions.
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? LOA LOP ROA ROP
Correct response: ROA Explanation: 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.
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 client is fully effaced. The fetus is floating high in the pelvis. The fetus is in the true pelvis and engaged. The fetus has descended down the birth canal.
Correct response: The fetus is in the true pelvis and engaged. Explanation: 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 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? diffuse abdominal cramping rupturing of fetal membranes start of regular contractions dilation of cervix diameter to 10 cm
Correct response: dilation of cervix diameter to 10 cm Explanation: The first stage of labor terminates with the dilation of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occurs 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 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 heart rate increase in blood pressure increase in respiratory rate slight decrease in body temperature increase in gastric emptying and pH
Correct response: increase in heart rate increase in blood pressure increase in respiratory rate Explanation: 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 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 pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: occurring in the abdomen and groin. lasting about 30 seconds. occurring about every 5 minutes. relieved by walking.
Correct response: occurring about every 5 minutes. Explanation: The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the women evaluated, especially if she is less than 38 weeks pregnant.
A client comes to the emergency department reporting strong contractions that have lasted for the past 2 hours. Which assessment will indicate to the nurse that the client is in true labor? progressive cervical dilatation and effacement pink show increased fetal activity 1:5 uterine contractions
Correct response: progressive cervical dilatation and effacement Explanation: True labor is defined as the onset of regular uterine contractions that cause progressive cervical dilatation and effacement. Pink show may occur 24 to 48 hours prior to birth. Increased fetal activity can occur at any stage. Thus, these are not indicators of true labor. There is no defined ratio of contractions when differentiating true from false labor.
A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client? Braxton Hicks contractions are not strong enough during first pregnancy. Contractions are stronger during the first pregnancy than the second. The cervix takes around 12 to 16 hours to dilate during first pregnancy. Spontaneous rupture of membranes occurs during first pregnancy.
Correct response: The cervix takes around 12 to 16 hours to dilate during first pregnancy. Explanation: The labor of a first-time-pregnant woman lasts longer because during the first pregnancy the cervix takes between 12 and 16 hours to dilate completely. The intensity of the Braxton Hicks contractions stays the same during the first and second pregnancies. Spontaneous rupture of membranes may occur before the onset of labor during each birth, not only during the first birth.
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.
Correct response: The frequency of the contractions is every 5 minutes. Explanation: 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 help in softening and ripening the cervix. These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions make maternal breathing easier.
Correct response: These contractions help in softening and ripening the cervix. Explanation: 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.
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? engagement descent restitution crowning
Correct response: crowning Explanation: 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.