OB - Intrapartum AQ

The nurse assesses a pregnant patient and finds that the patient has reduced strength of uterine contractions (UCs). Upon further assessment, the nurse suspects that the patient may have slow progress in labor. Which statement made by the patient indicates the reason for slow progress in labor? 1 "I have a family history of diabetes and hypertension." 2 "I stopped taking folic acid supplements a week ago." 3 "I have been on a diet with high amounts of protein for 15 days." 4 "I am worried a lot this time; I had a lot of problems in my last labor."

"I am worried a lot this time; I had a lot of problems in my last labor" The nurse suspects that the patient may have slow progress in labor after knowing that the patient is worried and stressed, because she had complications in the previous labor. Stress may reduce the progress in the labor by decreasing the levels of catecholamines

A pregnant patient does not allow her partner to touch her and wants to be left alone. What can the nurse suggest to the patient's partner in this situation? 1 "It is due to depression and loneliness." 2 "It is a common behavior during pregnancy." 3 "Massage would help to make your partner relax." 4 "You should leave your partner alone for few days."

"It is a common behavior during pregnancy" Many patients experience hyperesthesia or sensitivity to touch during the transition phase of labor and do not allow their partners to touch them. To prevent anxiety of the partner and to provide effective care, the nurse should inform the partner that this behavior is common during pregnancy.

While assessing a newborn immediately after vaginal birth, the mother is concerned that the newborn's head has assumed an abnormal shape. What should the nurse inform the mother of the baby? Select all that apply. A "Your baby's head should assume a normal shape within 3 days." B "Our physical therapist will be able to fix the shape of your baby's head." C "Our experienced pediatric surgeon will need to perform surgery on your baby's head." D "Applying baby oil daily for 2 weeks should help normalize the shape of your baby's head." E "This molding of the head allowed your child to adapt to the shape of your pelvis during labor."

"Your baby's head should assume a normal shape within 3 days." "This molding of the head allowed your child to adapt to the shape of your pelvis during labor A change in the shape of the newborn's head during delivery due to slight overlapping of the skull bones is called molding. The shape of the head becomes normal within 3 days. Molding allows the child's head to adapt to the shape of the mother's pelvis.

The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part? 1 -1 2 +1 3 +3 4 +5

+5 Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm.

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine. 2 1 cm above the ischial spine. 3 at the level of the ischial spine. 4 1 cm below the ischial spine.

1 cm above the ischial spine When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

The nurse notes that the fetus in a laboring patient is in brow presentation. What is the expected occipitomental diameter? 1 9.25 cm 2 9.5 cm 3 12.00 cm 4 13.5 cm

13.5 cm In a brow presentation, the presenting part is the mentum or chin. The occipitomental diameter is 13.5 cm at term, which is too large to permit the infant's head to enter the pelvis region of the mother. The biparietal diameter, which is about 9.25 cm at term, is the largest transverse diameter. The smallest anteroposterior diameteris, the suboccipitobregmatic diameter, which is about 9.5 cm at term, is in a vertex presentation. In a sinciput presentation, theoccipitofrontal diameter is about 12.00 cm at term, with moderate extension of the head.

The nurse is preparing to perform a nitrazine pH test on a pregnant patient. Arrange the steps that the student nurse would follow while conducting the test. 1. Soak the cotton-tipped applicator in the nitrazine dye. 2. Inform the patient and the partner about the procedure. 3. Document the test reports of the patient in the patient record. 4. Insert the cotton-tipped applicator deep into the vagina. 5. Perform perennial care in the patient as required.

2,1,4,5,3 A nitrazine dye test is performed to learn the status of the amniotic membrane in the pregnant patient. Informing the patient and her partner about the testing procedure makes the patient feel comfortable. The cotton-tipped applicator specified for this procedure is soaked in nitrazine dye. Then, the applicator is inserted into the vagina to get the fluid on the applicator. Perineal care is then performed to ensure that there is no risk of infections. Finally, the test result is seen and documented appropriately.

During the assessment of a 38-week pregnant patient, the nurse finds that the patient is experiencing false labor. After reviewing the medical history, the nurse finds that the patient had rapid labor during the previous pregnancy. What would be the most suitable nursing action? 1 Admit the patient to a latent labor room immediately. 2 Suggest that the patient rest at home until the labor progresses. 3 Inform the patient that cervical dilation of 5 cm indicates true labor. 4 Suggest that the patient take a cold shower to prevent uterine contractions (UCs).

Admit the patient to a latent labor room immediately The patient who is in false labor should be asked to wait until true labor begins. However, if the medical reports of the patient indicate that the patient had rapid labor during the previous pregnancies, then the patient must be admitted in the latent labor room. This helps prevent complications during the labor.

Under which circumstances should a vaginal examination be performed by the nurse? Select all that apply. 1 An admission to the hospital at the start of labor 2 When accelerations of the fetal heart rate (FHR) are noted 3 On maternal perception of perineal pressure or the urge to bear down 4 When membranes rupture 5 When bright, red bleeding is observed

An admission to the hospital at the start of labor On maternal perception of perineal pressure or the urge to bear down When membranes rupture Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM), a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

During the assessment, the nurse palpates the abdomen of a pregnant patient to identify the number of fetuses. Which actions should the nurse perform before conducting the assessment? Select all that apply. 1 Help the patient change positions often. 2 Ask the patient to empty the bladder completely. 3 Place a small rolled towel under the patient's hip. 4 Use running water to stimulate voiding of the patient. 5 Suggest that the patient lie in the supine position with a pillow under her head.

Ask the patient to empty the bladder completely Place a small rolled towel under the patient's hip Suggest that the patient lie in the supine position with a pillow under her head Leopold maneuvers involve abdominal palpitation to identify the number of fetuses and expected location of the point of maximal impulse (PMI) of the fetal heart rate (FHR) on the patient's abdomen. Therefore the nurse should ask the patient to empty the bladder, as the maneuver can be painful if the bladder is full. The nurse can suggest that the patient lie in the supine position with one pillow under her head to make the patient feel comfortable. The nurse should place a small rolled towel under the patient's right or left hip to prevent supine hypotensive syndrome.

The nurse is caring for a pregnant patient and suspects that the primary health care provider (PHP) would recommend a cesarean section. What could be the most probable reason for this? 1 Increased maternal pulse rate 2 Body mass index (BMI) is 32 kg/m2 3 Elevated blood glucose levels 4 High basal body temperature

Body mass index (BMI) is 32 kg/m2 A pregnant woman may have a higher risk of cesarean birth and cephalopelvic disproportion when the BMI is higher than 30 kg/m2. It indicates that a weight gain of 16 kg or more results in a BMI above 30 kg/m2. Therefore the nurse expects the patient to have cesarean birth because the patient's BMI is 32 (above 30) kg/m2.

The nurse is studying the chart of a patient in labor. If the patient's chart indicates "RMA," what is the presenting part? 1 Chin 2 Sacrum 3 Scapula 4 Occiput

Chin (Mentum) The chin or mentum is the presenting part of the fetus if the chart indicates "RMA." If the sacrum is the presenting part, the middle letter is S. If the scapula is the presenting part, the middle letter is Sc. If the occiput is the presenting part, the middle letter is O.

The nurse is caring for a pregnant patient. What interventions should the nurse follow to ensure proper hygiene in the patient? 1 Clean the perineum of the patient frequently. 2 Clean the patient's teeth with a warm wet cloth. 3 Offer a warm washcloth to the patient for a face wash. 4 Allow cool water to flow on the patient's back for 5 minutes.

Clean the perineum of the patient frequently The patient's perineum should be cleaned frequently to prevent the risk for infection. This helps maintain proper hygiene and provides comfort to the patient.

The nurse is caring for a patient in the first stage of labor. What maternal physiologic changes does the nurse expect? 1 Decrease in absorption of solid food 2 Increase in systolic and diastolic pressures 3 Increase in nausea and vomiting sensation 4 Increase in cardiac output by 30% to 50%

Decrease in absorption of solid food During the first stage of labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed down. Only systolic blood pressure increases during uterine contractions in the first stage of labor. Systolic and diastolic pressures increase during contractions in the second stage of labor and return to baseline levels between contractions. Nausea and vomiting sensations may occur during the transition from first stage to second stage of labor. In the first stage of labor, the cardiac output increases by 10% to 15%. Cardiac output increases by 30% to 50% only at the end of the first stage of labor and not in the first stage.

Which characteristic is associated with false labor contractions? 1 Painful 2 Decrease in intensity with ambulation 3 Regular pattern of frequency established 4 Progressive in terms of intensity and duration

Decrease in intensity with ambulation Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. True labor contractions are painful. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.

After reviewing the laboratory reports of a pregnant patient at term, the primary health care provider (PHP) advised the nurse to administer intravenous (I.V.) fluids to the patient. What is the reason for giving such advice? 1 Dehydration 2 Hypertension 3 Maternal hyperglycemic 4 Preterm labor

Dehydration I.V. fluids are administered to increase the amount of fluids and restore the electrolyte balance. As the patient is dehydrated, the PHP advises the nurse to administer I.V. fluids. Administration of I.V. fluids as a medical treatment for the prevention of preterm labor is not indicated unless medical management involves use of therapeutic protocols such as magnesium sulfate.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? 1 The healthy newborn should be taken to the nursery for a complete assessment. 2 After drying, the infant should be given to the mother wrapped in a receiving blanket. 3 Encourage skin-to-skin contact of mother and baby. 4 The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

Encourage skin-to-skin contact of mother and baby The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding.

After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? 1 Help the patient to lie in supine position on the bed. 2 Encourage the patient to sit in hands-and-knees position. 3 Place a pillow under the patient's hip when lying in supine position. 4 Ask the patient to lie in lateral position on the opposite side of the fetal spine.

Encourage the patient to sit in hands-and-knees position The nurse should place the patient in a position that helps the rotation of the fetal occiput from a posterior to an anterior position. Therefore the nurse should encourage the patient to sit in hands-and-knees position, as it increases the pelvic diameter, allowing the head to rotate toward anterior position. The patient should not lie in supine position, as it may cause postural hypotension. Placing a pillow under the patient's hip when lying in supine position helps prevent supine hypotensive syndrome, but does not help in delivering the baby. The nurse should not ask the patient to lie in lateral position on the opposite side of the fetal spine, as it increases counter pressure on the back. Instead, lying in lateral position on the same side of the fetal spine will help the fetus rotate toward the posterior, as the gravity pulls the fetal back forward.

The nurse is caring for a Southeast Asian patient who gave birth to a child. What interventions can the nurse perform to promote bonding between the newborn and the family? Select all that apply. 1 Placing the hand on the infant's head 2 Encouraging the sibling to hold the baby 3 Explaining the molding of the infant's head 4 Praising the infant's appearance and health 5 Explaining the dusky appearance of the infant

Encouraging the sibling to hold the baby Explaining the molding of the infant's head Explaining the dusky appearance of the infant The parents may be worried about the newborn's dusky appearance. Therefore the nurse should properly explain to the parents that the baby may initially appear dusky. The color may become normal once the circulation is established. Siblings may be encouraged to hold the newborn to promote bonding between them. The infant's head is molded due to the narrowness of the birth canal and the pelvic structures. This is to be explained to the parents. Southeast Asian patients consider the head to be the sacred part of the human body and should not be touched. Hence, the nurse should avoid placing hand on the infant's head. The Southeast Asian population considers any praise of the infant as harmful, as they believe the jealous spirits will take away the baby.

The nurse is caring for a patient in labor with a history of sexual abuse. What interventions should the nurse perform while caring for the patient? Select all that apply. 1 Explain the need of the procedures. 2 Ask the patient about past memories. 3 Limit the number of invasive examinations. 4 Obtain the patient's permission to touch her. 5 Avoid assessing the uterine contractions (UCs).

Explain the need of the the procedures Limit the number of invasive examinations Obtain the patient's permission to touch her The nurse should be extremely cautious about not saying anything to the patient that would remind her of the history of sexual abuse. Therefore the nurse should not discuss the patient's past memories, as it could be distressing. However, the nurse should explain all the medical procedures that are required during the examination to relieve the patient's anxiety. The health care team should try to limit the number of invasive procedures as they might trigger the sexual abuse memories. The nurse should obtain the patient's permission before touching her to give the patient a sense of control. UCs help to assess the onset of labor.

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? The laceration: 1 Also involves the anterior rectal wall. 2 Continues through the anal sphincter muscle. 3 Extends through muscles of the perineal body. 4 Extends through the skin and structures superficial to muscles.

Extends through the skin and structures superficial to muscles A first-degree laceration extends through the skin and structures superficial to muscles. A second-degree laceration extends through muscles of the perineal body. A third-degree laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall.

What are the factors that enable the baby to initiate respiration immediately after birth? 1 Fetal respiratory movements increase during labor. 2 Fetal lung fluid is cleared from the air passage. 3 Arterial carbon dioxide pressure is decreased. 4 Arterial pH and bicarbonate level is increased.

Fetal lung fluid is cleared from the air passage Fetal lung fluid is cleared from the air passage as the infant passes through the birth canal during labor and vaginal birth. There is a decrease in fetal respiratory movements during labor. Arterial carbon dioxide pressure (Pco2) increases. There is a decrease in arterial pH and bicarbonate levels.

On interacting with the partner of a pregnant patient, the nurse suggests that the partner soothe the patient's forehead, palms of her hands, and soles of her feet. What patient observation could be the possible reason for such advice to the partner? 1 Hyperesthesia 2 Flushing of cheeks 3 Bladder distension 4 Postural hypotension

Hyperesthesia The pregnant patient becomes more sensitive to touch as the labor progresses. This condition is called hyperesthesia. Soothing the surfaces of the body where hair does not grow can reduce this sensitivity. These areas include the patient's forehead, palms of the hands, and soles of the feet.

Upon assessment, the nurse suspects that a pregnant patient has potential complications during the early phase of labor. Which signs in the patient correspond to the nurse's suspicion? Select all that apply. 1 Temperature of 36.5o C 2 Intrauterine pressure of 85 mm Hg 3 Uterine contractions (UCs) lasting for 92 seconds 4 Uterine contractions (UCs) lasting for 40 seconds 5 Relaxation between uterine contractions (UCs) lasting for 25 seconds

Intrauterine pressure of 85 mm Hg Uterine contractions (Cus) lasting for 92 seconds Relaxation between uterine contractions (Cus) lasting for 25 seconds The pregnant patient is likely to have potential complications during the early phase of labor if the UCs last more than 90 seconds. Long UCs can compromise the fetal perfusion. An intrauterine pressure of above 80 mm Hg and relaxation between the UCs lasting less than 30 seconds indicates impaired fetal perfusion. The temperature of 36.5o C and UCs lasting for 40 seconds are not the signs of potential complications during early labor. The temperature above 38o C and UCs lasting more than 40 seconds indicates potential complications during the early phase of labor.

The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? 1 It is diamond shaped in appearance. 2 It measures about 1 cm by 2 cm. 3It closes after 6 to 8 weeks of birth. 4It lies near the occipital bone.

It is diamond shaped in appearance The anterior fontanel is diamond shaped and measures about 3 cm by 2 cm. It closes by 18 months after birth. It lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel is triangular in shape and measures about 1 cm by 2 cm.

The nurse assisting a laboring patient recognizes the Ferguson reflex in the patient. What is the Ferguson reflex? 1 Release of endogenous oxytocin 2 Involuntary uterine contractions 3 Maternal urge to bear down 4 Mechanical stretching of the cervix

Maternal urge to bear down The maternal urge to bear down is known as the Ferguson reflex. The Ferguson reflex occurs when stretch receptors in the posterior vagina cause the release of endogenous oxytocin.

A patient in labor exhibits flushed cheeks. The nurse records the uterine contractions in the patient as being 3 to 5 minutes apart and lasting for about 1 minute. What nursing intervention is most effective to assess the patient's status during this phase of labor? 1 Check blood pressure every 2 hours. 2 Note patient's appearance and mood every 15 minutes. 3 Assess the patient's temperature every 2 hours until membranes rupture. 4 Monitor temperature every 4 hours after membranes rupture.

Note the patient's appearance and mood every 15 minutes The patient is experiencing uterine contractions that are 3 to 5 minutes apart and last for about 60 seconds (1 minute). The patient also exhibits flushed cheeks. These findings indicate that the patient is in the active phase of the first stage of labor. The nursing assessment in the active stage of labor is to check the patient's appearance and mood every 15 minutes, or 4 times in an hour. The patient's mood and energy levels fluctuate, and therefore the nurse should constantly assess them to ensure effective patient care. The patient's blood pressure should be assessed every 30 minutes. The nurse should assess the patient's body temperature every 4 hours until membrane rupture and thereafter every 2 hours.

Which patients are more susceptible to soft-tissue damage with vaginal deliveries? Select all that apply. 1 Multiparous patients 2 Nulliparous patients 3 Patients needing forceps delivery 4 Patients with fetal vertex presentation 5 Patients with fetal breech presentation

Nulliparous patients Patients needing forceps delivery Patients with fetal breech presentation A nulliparous patient has rigid perineal tissue making it susceptible to injury. Fetal breech presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps delivery also increases the risk of injury due to undue stretch of the perineum.

A patient has been admitted to the labor room. What are the measures to be taken by the nurse to support the partner of the patient? Select all that apply. 1 Offer snacks and fluids to the partner as required. 2 Do not discuss the psychological change in the patient. 3 Demonstrate the performance of the comfort measures. 4 Guide the partner to make decisions about his involvement. 5 Relieve the person occasionally from the job of supporting the patient.

Offer snacks and fluids to the partner as required Demonstrate the performance of the comfort measures Relieve the person occasionally from the job of supporting the patient Any comfort measures useful for the patient should be demonstrated to the patient's partner. The patient's partner may be reminded to take food. The nurse can also offer snacks and fluids to the partner. The nurse can offer to relieve him of the duty of supporting and encouraging the patient in order to get proper rest.

The nurse is caring for a patient in labor whose cervix is dilated to 10 cm and who is exhibiting copious amounts of bloody mucus show. What behavior does the nurse anticipate finding in this patient? Select all that apply. A The patient expresses the need to defecate. B The patient finds it difficult to follow instructions. C The patient readily listens to the nurse's instructions. D The patient doubts her ability to continue with the labor. E The patient expresses the need to have a caretaker at her bedside.

Patient expresses need to defecate The patient doubts her ability to continue with the labor The patient in labor is dilated by 10 cm and exhibits copious amounts of bloody mucus show. These findings indicate that the patient is in the transition phase of the first stage of labor. In the transition phase, the patient experiences pressure on the anus and therefore feels the need to defecate. The patient may also express doubts about her ability to continue with the labor in this phase.

What are the common signs that are observed in the days preceding labor? Select all that apply. 1 Persistent low backache 2 Sudden increase in lethargy 3 Blood-tinged cervical mucus 4 Increase in weight up to 1.5 kg 5 Profuse vaginal mucus

Persistent low backache Blood-tinged cervical mucus Profuse vaginal mucus Common signs that precede labor include persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Brownish or blood-tinged cervical mucus may be passed. The vaginal mucus becomes more profuse in response to the extreme congestion of the vaginal mucous membranes.

During a prenatal evaluation, the nurse notes that the patient has a flat pelvis. What term does the nurse use to refer to this type of pelvis? 1 Gynecoid 2 Android 3 Anthropoid 4 Platypelloid

Platypelloid About 3% of women may have a flat pelvis, which is referred to as a platypelloid pelvis. It is flattened anteroposteriorly and wide transversely. About 50% of women have gynecoid pelvis or the classic female type of pelvis. It is slightly ovoid or transversely rounded. An android pelvis resembles the male pelvis and may be found in 23% of women. It is heart shaped or angulated. The anthropoid pelvis resembles the pelvis of anthropoid apes and may be found in 24% of women. It is oval and wider anteroposteriorly.

Upon reviewing the laboratory reports of a pregnant patient, the nurse reports to the primary health care provider (PHP) that the patient has impaired nutrition. Which finding enabled the nurse to conclude this? 1 Discoloration of the patient's urine specimen 2 High specific gravity of the patient's urine specimen 3 Presence of ketones in the patient's urine specimen 4 Presence of leukocytes in the patient's urine specimen

Presence of ketones in the patient's urine specimen The presence of ketones in the urine specimen indicates that the patient has impaired nutrition due to the presence of excess glucose in the blood. Abnormal levels of leukocytes, discoloration of urine, and abnormal specific gravity of the urine do not give information about nutrition. Abnormal levels of leukocytes indicate the presence of infection. Discoloration of the urine and high specific gravity of the urine indicates dehydration resulting from loss of fluids.

The nurse observes that a pregnant patient has a blood glucose level of 180 mg/dL in early labor. Which medication order does the nurse expect to receive from the primary health care provider (PHP)? 1 Lidocaine (Nervocaine) to the patient 2 Ringer's lactate solution to the patient 3 Hydromorphone (Dilaudid) to the patient 4 Intravenous (IV) solution containing a small amount of dextrose

Ringers lactate solution to the patient The blood glucose level of 180 mg/dL indicates that the patient has high blood glucose levels. Therefore the patient has to be administered an electrolyte solution without glucose to prevent the risk of fetal hyperglycemia and hyperinsulinism. Hence, the nurse would expect the PHP to prescribe Ringer's lactate solution to the patient, as it does not increase blood sugar levels.

After a vaginal examination, the nurse documents "RSA" on the patient's chart. What does this indicate? The presenting part is the: 1 Sacrum in the left anterior quadrant of the maternal pelvis. 2 Scapula in the right anterior quadrant of the maternal pelvis. 3 Sacrum in the right anterior quadrant of the maternal pelvis. 4 Scapula in the left transverse quadrant of the maternal pelvis.

Sacrum in the right anterior quadrant of the maternal pelvis Fetal position is denoted by a three-letter abbreviation. The first letter denotes the location of the presenting part in the right (R) or left (L) side of the mother's pelvis. The middle letter stands for the specific presenting part of the fetus: O for occiput, S for sacrum, M for mentum, and Sc for scapula. The third letter stands for the location of the presenting part in relation to the anterior (A), posterior (P), or transverse (T) portion of the maternal pelvis. RSA indicates that the presenting part is the sacrum in the right anterior quadrant of the maternal pelvis. LSA indicates that the presenting part is the sacrum in the left anterior quadrant of the maternal pelvis. RScA shows that the presenting part is the scapula in the right anterior quadrant of the maternal pelvis. LScT indicates that the presenting part is the scapula in the left transverse quadrant of the maternal pelvis.

The nurse restricts the visitors of a pregnant patient and gives a specific time for the patient to rest and sleep after the labor. What maternal patient experience could be the probable reason for this nursing action? 1 Severe pain during labor 2 Severe fatigue during labor 3 Ineffective birth process 4 Problem of irregular urination

Severe fatigue during labor The patient may have severe fatigue after labor due to depletion of energy. In order to restore the energy levels, the nurse gives a specific time for the patient to rest and sleep by restricting the visitors.

During the vaginal examination of a patient in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation does the nurse recognize? 1 Cephalic 2 Frank breech 3 Complete breech 4 Shoulder

Shoulder The presenting part can be defined as that part of the fetus that lies closest to the internal os of the cervix. In the shoulder presentation, the presenting part is the scapula. In a cephalic presentation, the presenting part is usually the occiput. In a breech presentation, the presenting part is the sacrum. The sacrum is the presenting part in a frank breech presentation. The sacrum and feet are the presenting parts in a complete breech presentation.

A full-term pregnant patient reports labor pain. What would be the nature of contractions if the patient has false labor? Select all that apply. 1 Do not stop with change in position 2 Stop with use of comfort measures 3 Stop when the patient starts walking 4 Felt in back and abdomen above navel 5 Become stronger and last longer over time

Stop with the use of comfort measures Stop when the patient starts walking Felt in the back and abdomen above navel The nurse should be able to distinguish between false and true labor. In false labor, the contractions usually stop if the patient is placed in a comfortable position or if the patient walks. Unlike true labor, the contractions of false labor are felt above the navel. The contractions of true labor do not stop with a change in position, and they usually become stronger and last longer over time.

What are the factors that speed up the dilation of the cervix? Select all that apply. 1 Strong uterine contractions 2 Scarring of the cervix 3 Pressure by amniotic fluid 4 Prior infection of the cervix 5 Force by fetal presenting part

Strong uterine contractions Pressure by amniotic fluid Force by fetal presenting part Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are, in turn, caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation.

The nurse is performing a vaginal examination of a pregnant patient who is in the first stage of labor. During the examination, the patient reports that she has an urge to bear down. Why does the patient feel this urge? Select all that apply. A The descending part of the fetus reaches the pelvic floor. B The presenting part of the fetus descends into the true pelvis. C Levels of estrogen increase and levels of progestogen decrease. D Levels of progestogen increase and levels of estrogen decrease. E Levels of oxytocin increase due to activation of stretch receptors in the vagina.

The descending part of the fetus reaches the pelvic floor Levels of oxytocin increase due to activation of stretch receptors in the vagina When the presenting part of the fetus reaches the pelvic floor, it activates stretch receptors in the posterior vagina and releases endogenous oxytocin in a pregnant woman, which causes the urge bear down and push the baby out. This phenomenon is called the Ferguson reflex. The presenting part of the fetus descends into the true pelvis about 2 weeks before term; this "dropping" does not cause the urge to bear down. Levels of estrogen and progestogen do not change due to vaginal stimulation. Receptors in the vagina are activated rather than inhibited, which releases oxytocin and causes the urge to push.

The nurse informs the patient that she will likely have difficulty delivering vaginally, and a cesarean delivery may be necessary. Which findings led the nurse to this conclusion? Select all that apply. A The patient has a gynecoid pelvis. B The patient has an android pelvis. C The patient has an anthropoid pelvis. D The fetus is in a cephalic presentation. E The fetal head is in a brow presentation.

The patient has an android pelvis the fetal head is in a brow presentation The android pelvis is heart-shaped, and it resembles the male pelvis. The pelvic outlet in this type is very narrow, which may make vaginal delivery difficult. Thus, the patient with this type of pelvis is most likely to require a cesarean delivery. If the fetal head is in a brow position, the diameter of the head is often too large to pass through the pelvis; therefore, a resolution is required before vaginal delivery, or a cesarean delivery is necessary.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

Third The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

The primary health care provider (PHP) advised the nurse to assess the maternal temperature and vaginal discharge of a pregnant patient every 2 hours. What is the reason behind this advice? 1 To evaluate fetal status 2 To know the onset of labor 3 To assess for potential risk for infection 4 To prevent fetal hypertension

To assess for potential risk for infection When the membranes rupture, there is a possible risk of infection, as the microorganisms can ascend form the vagina to the uterus. Ruptured membranes can be assessed by monitoring the body temperature and vaginal discharge every 2 hours.

A patient has been laboring for several hours and after checking the patient's cervix, the nurse finds the patient's cervix is dilated 9 cm and the patient is having strong uterine contractions (UCs) each lasting for 45 to 90 seconds. Based on these observations, the nurse determines that the patient is in which stage of labor? 1 Latent phase of the first stage of labor 2 Active phase of the first stage of labor 3 Active phase of the second stage of labor 4 Transition phase of the first stage of labor

Transition phase of the first stage of labor The first stage of labor consists of three phases: the latent phase, active phase, and transition phase. Strong UCs and cervical dilation of 8 to 10 cm can be observed during the transition phase of labor. Moderate to strong UCs and cervical dilation of 4 to 7 cm can be observed during the active phase of labor. Mild to moderate UCs and cervical dilation of 0 to 3 cm can be considered the latent phase of labor. The second stage is known as the fetal expulsion stage. It begins when the cervix is fully dilated and ends when the baby is born.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: 1 encouraging the woman to try various upright positions, including squatting and standing. 2 telling the woman to start pushing as soon as her cervix is fully dilated. 3 continuing an epidural anesthetic so that pain is reduced and the woman can relax. 4 coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

encouraging the woman to try various upright positions, including squatting and standing Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing.

Which pelvic shape is most conducive to vaginal labor and birth? 1 Android 2 Gynecoid 3 Platypelloid 4 Anthropoid

gynecoid The gynecoid pelvis is round and cylinder shaped, with a wide pubic arch. Prognosis for vaginal birth is good. Only 23% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The platypelloid pelvis is flat, wide, short, and oval. The anthropoid pelvis is a long, narrow oval with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape.

For the labor nurse, care of the expectant mother begins with which situations? Select all that apply. 1 The onset of progressive, regular contractions 2 The bloody, or pink, show 3 The spontaneous rupture of membranes 4 Formulation of the woman's plan of care for labor 5 Moderately painful contractions

the onset of progressive, regular contractions the bloody, or pink, show the spontaneous rupture of membranes