module 5
The nurse is preparing to instruct Margarette regarding her findings of left sacrum anterior. The nurse should include which of the following in the teaching plan?
"Your baby's hips are flexed and the knees are extended."
he nurse is reviewing the progress of labor of a pregnant woman. The nurse notes that the physician documented that the woman has circular shaped, moderate depth, wide pubic arch, moderately curved sacrum on internal examination. An internal examination was done and the nurse was instructed to chart his findings of the patient's diagonal conjugate 12.5 cms and the height of the symphysis pubis is normal. The nurse estimates the obstetric conjugate as approximately:
10.5
The nurse is monitoring the client in labor. The nurse performed abdominal palpation to assess the frequency, duration, and strength of the contractions of the client in labor. Client's data include "8 am.: contraction, moderate, lasts 45 sec; 8:05 am.; contraction moderate, lasts for 45 sec.; 8:10 am; contraction moderate, lasts for 45 seconds. Based on these data, the nurse would correctly interpret the client's INTERVAL of uterine contractions as:
4 minutes and 15 seconds
SITUATION: Margarette Uy is a primigravida admitted to the labor unit at 40 weeks gestation. Vaginal exams revealed that her cervix is 8 cm dilated, 80% effaced, and the presenting part is at zero station, membranes intact. During a vaginal examination of Margarette, the nurse palpates the fetal head and a large diamond-shaped fontanel. The nurse correctly interprets this which type of fetal presentation?
Brow Presentation
Nurse Sweetie is assisting a client in the labor room. While performing Leopold's Maneuver, which of the following finding will tell you that the fetus occupies cephalic presentation?
During first maneuver when you feel a slightly broad mass, somewhat soft and somewhat hard and moves with the fetal body
A nurse performed a vaginal examination of a laboring client. The nurse determines that labor is progressing and the cervix is 8 cms dilated, 75% effaced. The client enters the transition phase of the first stage of labor. Which nursing action best meets the client's needs during the transition phase?
Frequently praising the client
An internal examination of a 20 vear old client revealed the following: cephalic presentation, cervix 3 cms dilated, 75% effaced, station is -1, frequency is 2-3 minutes, duration 45 seconds, moderate intensity. When asked to perform the partograph, which of the following indicates that the nurse needs further teaching?
Latent phase of labor
A pregnant client was admitted to the labor room. An assessment is performed. Internal Examination was done and the result is 2 cm. cervical dilation, 50% effaced, Station -1, the distance between ischial spines are wide and amniotic sac is intact. Which of the following is an appropriate interpretation of the nurse?
Latent phase, thinning of the cervical canal 1 cm in thickness, unengaged, adequate pelvis
A nurse in the labor room is monitoring the client in labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration and intensity. The priority nursing intervention in caring for the client is to:
Monitor the fetal heart tones
Martina Williams is a primigravida who has just been admitted to the labor unit. After Mrs. William's orientation to the labor unit, the nurse applies the external fetal monitor and conducts a vaginal examination. She also asks the nurse what causes labor to begin. Which of the following statements is a possible explanation of the nurse?
Prostaglandins may be the causative factors of labor
The nurse informed a pregnant client in labor that the smallest head diameter of the fetus must be presented to the birth canal in order to best traverse/travel to the birth canal. Which of the following is the smallest anterioposterior cranial diameter of a fetus?
Suboccipito bregmatic
Situation: After the vaginal examination, the physician indicates that the client is in the latent phase of the first stage of labor. A progress note is written in the client's admission records. When the nurse reviews the client's admission records, which assessment finding is most reliable indicator the client is in true labor?
The cervix is dilated
Situation: A 29 year old multiparous client who has had an uneventful healthy pregnancy is admitted to the hospital. The physician informs the client is in the active phase of labor. The record also shows that the full term baby is in the left occiput posterior position. The nurse correctly says that the following are signs indicating that the labor is progressing, EXCEPT one:
The duration becomes longer lasting for 10 to 20 minute
The laboring client is 8 cms dilated, 100 percent effaced, with vertex presenting at +2 station. The fetal heart rate gradually slows during each contraction, returning to baseline by the end of the contraction. The nurse concludes that which of the following is the explanation of the client's condition?
The fetal head is becoming compressed.
SITUATION: A 25 year old primigravida client in her last trimester of pregnancy calls the physician's office and tells the nurse that she thinks she is in labor. She has several concerns regarding her upcoming labor. What would be the first sign of impending or approaching labor? Your correct response should be: she will have to experience EXCEPT:
Weight gain and edema
The client arrives at the hospital and is admitted to the feto-maternal unit for labor monitoring. The client informs the nurse that she was admitted to the unit 3 days ago but that turned out to be a false labor. The nurse examines the client obtaining the vital signs. When is the most appropriate time to take the client's vital signs?
With the client positioned on her left side, between contraction