OB R&R ch 8 (the normal L&D experience)

Which statement would indicate that the laboring client needs further education? 1. "Because this is my first labor, I will need an epidural." 2. "Labor can be long and difficult sometimes." 3. "I should keep taking at least ice chips throughout labor." 4. "My partner can help me stay relaxed and focused."

1. "Because this is my first labor, I will need an epidural." Rationale: Analgesia and anesthesia methods are used for pain relief during labor as indicated by the client's response to pain, what phase and stage of labor the woman is in, how fast labor is progressing, and the fetal response to contractions. Parity alone does not determine what analgesia or anesthesia is indicated. The other responses are all accurate.

The pregnant client is seven cm dilated, 100% effaced, and at a +1 station. The fetus is in a face presentation. The nurse concludes that client teaching has been effective when the client's husband makes which statement? 1. "Our baby will come out face first." 2. "Our baby will come out facing one hip." 3. "Our baby will come out buttocks first." 4. "Our baby will come out with the back of the head first."

1. "Our baby will come out face first." Rationale: Presentation refers to the part of the fetus that is coming through the cervix and birth canal first. Thus, a face presentation occurs when the face is coming through first. This is considered a position of caution as the face is a large part of the head. It must be dealt with cautiously. .

The nurse notes on the antepartal history that the pregnant client has an android pelvis. The nurse concludes that this client is at an increased risk for which of the following? 1. A prolonged labor 2. Occiput posterior position 3. Precipitous delivery 4. Postpartum hemorrhage

1. A prolonged labor Rationale: An android pelvic structure is narrow in both the anterior-posterior diameter and the lateral diameter, and can cause prolonged labor if there is a large fetus or a malpositioned fetus. An android pelvic structure does not increase the likelihood of occiput posterior position, precipitous delivery, or postpartum hemorrhage.

The client's vaginal examination reveals: three centimeters dilated, 80% effaced, vertex at zero station. The woman is talkative and appears excited. The nurse determines the client to be in which stage and phase of labor? 1. First stage, latent phase 2. First stage, active phase 3. Second stage, latent phase 4. Third stage, transition phase

1. First stage, latent phase Rationale: The first stage of labor is from the onset of labor to complete dilatation, and is divided into latent (0 to 3 centimeters), active (4 to 7 centimeters), and transition (8 to 10 centimeters) phases. The second stage of labor has no phases and extends from complete dilatation until delivery of the newborn. The third stage has no phases and extends from delivery of the newborn to delivery of the placenta.

Earlier in the day, the baseline fetal heart rate (FHR) on a laboring client's fetus was 140. It is now 170. The nurse considers that which of the following could be an explanation for this change? Select all that apply. 1. Maternal fever 2. Narcotic administration 3. Fetal movement 4. Utero-placental insufficiency 5. Fetal distress

1. Maternal fever 5. Fetal distress Rationale: An increase in FHR baseline can be an indication of fetal distress and can also occur with maternal fever. Narcotics may decrease the short-term variability but do not affect the baseline. Fetal movement will create an acceleration of the fetal heart rate. Utero-placental insufficiency causes late decelerations.

The nurse performs a vaginal examination and determines that the fetus is in a sacrum anterior position. The nurse draws which conclusion from this assessment data? 1. The fetal sacrum is toward the maternal symphysis pubis. 2. The fetal sacrum is toward the maternal sacrum. 3. The fetal face is toward the maternal sacrum. 4. The fetal face is toward the maternal symphysis pubis.

1. The fetal sacrum is toward the maternal symphysis pubis. Rationale: The presenting part is given first when describing fetal position. The second half of the fetal position description refers to the maternal pelvis. In this client, it is the sacrum presenting, and the fetal sacrum is toward the maternal anterior pelvis. The fetal sacrum is not a standard reference point. In this question, the sacrum (not the face) is being described. The maternal sacrum is also the posterior part of the maternal pelvis. The fetal sacrum (not the fetal face) is being described in this question. C.

The nurse determines teaching has been effective when a laboring client makes which statement? 1. "Effacement is the opening of my cervix." 2. "My cervix will probably efface before it dilates because this is my first pregnancy." 3. "Effacement is measured from 0 to 10 centimeters." 4. "My cervix will efface and dilate at the same time because this is my first pregnancy."

2. "My cervix will probably efface before it dilates because this is my first pregnancy." Rationale: Effacement is the thinning of the cervix from 0 to 100%. The opening of the cervix from 0 to 10 centimeters is called dilatation. In primigravidas effacement usually precedes dilatation while in multigravidas these processes usually occur concurrently.

The nurse determines that a laboring client is exhibiting signs of increased anxiety. The nurse anticipates that this may result in which of the following? 1. A rapid progression of labor 2. Increased pain during the labor process 3. Lack of a support from support person or system 4. The need for an episiotomy

2. Increased pain during the labor process Rationale: Anxiety commonly increases the perception of pain, and childbearing is no exception to this. Decreasing anxiety through education and support will facilitate the birthing process. Anxiety will not hasten the labor process. The client's anxiety level is not expected to reduce or eliminate the support from a support person or system. The need for an episiotomy would be determined by the status of the perineum, not the client's anxiety.

As labor progresses, the nurse expects to assess that a client's contractions are developing which characteristics? 1. More intense, less frequent, and of longer duration 2. More intense, more frequent, and of longer duration 3. Constant in intensity, more frequent, and of shorter duration 4. Constant in intensity and frequency, but of shorter duration

2. More intense, more frequent, and of longer duration Rationale: As labor progresses, contractions will become more intense, occur more frequently (shorter resting phase between contractions), and have an increasing duration. Less frequent or shorter duration contractions can impede labor progress

The fetal head is determined to be presenting in a position of complete extension. The maternal newborn nurse should anticipate which type of labor and delivery? 1. Precipitous labor and delivery 2. Prolonged labor and possible cesarean delivery 3. Normal labor and spontaneous vaginal delivery 4. Forceps-assisted vaginal delivery

2. Prolonged labor and possible cesarean delivery Rationale: The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, particularly the position of the head, present larger diameters to the maternal pelvis, which contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery.

The nurse anticipates that assessment of a normal episiotomy immediately post-delivery is most likely to reveal which of the following? 1. Gaping between the sutures 2. Slight yellow brown bruising 3. Purulent drainage from the suture line 4. Edema at the episiotomy site making the tissue appear shiny

2. Slight yellow brown bruising Rationale: Moderate ecchymosis and edema are a normal response to the trauma of childbirth, as well as to the presence of sutures. As this heals, the bruising takes on a slight yellow brown appearance. Sutures should be closely aligned without gaps. There should be no purulent-like drainage, which would indicate infection. Edema severe enough to cause the tissue to look shiny or taut is abnormal.

The maternal newborn nurse would use which description of the fetal position when explaining to the mother the occurrence of a frank breech position? 1. "Both the hips and the knees are flexed." 2. "The hips are extended and the knees are flexed." 3. "The hips are flexed and the knees are extended." 4. "Both the hips and the knees are extended."

3. "The hips are flexed and the knees are extended." Rationale: Frank breech position is when the sacrum of the baby is presenting, the hips are flexed, and the feet are extended upward toward the fetal head. Both hip and knee flexion occurs with a complete breech. Hip extension with knee flexion is characteristic of a kneeling breech. And both hip and knee extension occur with a double footling breech.

The nurse would formulate what general goal when developing childbirth education classes for pregnant women in the community? 1. Provide education for all pregnant clients. 2. Ensure a normal spontaneous vaginal delivery. 3. Assist clients to know what to expect during labor. 4. Prepare the couple for any possible complications.

3. Assist clients to know what to expect during labor. Rationale: The goal of childbirth education classes is to teach pregnant women and their support person(s) the birth process, strategies to cope with the pain of labor and to facilitate an easier labor, what to expect during childbirth, an understanding of operative delivery (use of forceps, vacuum extraction, and cesarean birth), and common procedures that may be performed throughout the birthing process. Many pregnant families get the information they need about the childbearing process by reading or from friends and extended family members. Childbirth preparation cannot prevent complications and thus cannot ensure vaginal deliveries for all clients.

Fourth-stage nursing care for a client with an episiotomy includes which of the following? Select all that apply. 1. Application of ice beginning four hours after delivery 2. Ice pack to the perineum for up to 60 minutes (min) per application 3. Inspection every 15 min during the first hour after birth 4. Instructions to avoid intercourse for at least 12 weeks 5. Ice packs to be applied for 20-30 min and removed for at least 20 min

3. Inspection every 15 min during the first hour after birth 5. Ice packs to be applied for 20-30 min and removed for at least 20 min Rationale: Frequent inspection for redness, swelling, tenderness, and hematoma is essential to fourth-stage nursing care. Pain relief begins with immediate application of ice. Ice packs should be applied for 20 to 30 minutes and removed for at least 20 minutes. If ice is applied for more than 30 minutes, vasodilation and edema may occur. Clients are usually advised to wait until bleeding stops and stitches heal (about three weeks) before resuming sexual activity, but this teaching would be part of the client's discharge instructions, and is not appropriate during the fourth stage of labor.

Which of the following nursing observations would indicate a sign of impending placental separation and expulsion? 1. Steady trickle of blood with an unchanged cord length 2. Lengthening of the cord with associated cord tear 3. Small gush of blood with lengthening of the cord 4. Small gush of blood with an unchanged cord length

3. Small gush of blood with lengthening of the cord Rationale: As the uterus contracts and the placenta begins to shear off the uterine wall for expulsion, there is a small gush of blood resulting from the uterine contractions emptying the uterus. In addition, the cord will lengthen as the placenta is released from the uterine wall and moves toward the cervix prior to expulsion. There should not be an associated cord tear.

After performing a vaginal exam the nurse discussed the results with the client and her partner. The nurse later concludes that client teaching was effective when the partner shouts, "She must be crowning; this means it will be soon," after viewing which of the following? 1. A little of the baby's head is pushing through the cervical opening. 2. The baby's head recedes upward between pushing contractions. 3. The perineum is thin and stretching around the occiput. 4. The mouth and nose are being suctioned.

3. The perineum is thin and stretching around the occiput. Rationale: Crowning is the point in time when the perineum is thin and stretching around the fetal head both between and during contractions. Delivery is imminent when crowning occurs.

Which of the following would be the highest priority of the nurse who is caring for the laboring client? 1. More intense, less frequent, and of longer duration 2. More intense, more frequent, and of longer duration 3. Constant in intensity, more frequent, and of shorter duration 4. Constant in intensity and frequency, but of shorter duration

4. Constant in intensity and frequency, but of shorter duration Rationale: The fetal heart rate response to contractions is a physiologic assessment that indicates the presence or absence of fetal well-being. Providing pain relief measures, assessing partner involvement, and monitoring fluid intake are appropriate for the laboring client, but safety of the fetus and the mother are the highest priorities.

The client has been having contractions every five minutes for seven hours. Which factor would the nurse use to determine if this is true labor? 1. The cervix is showing a pattern of effacement and dilatation. 2. The client has given birth to three children previously. 3. The contractions increasing in intensity and duration. 4. There was a spontaneous rupture of membranes.

Answer: 1 Rationale: Changes in the cervix, showing a pattern of continuous dilatation and effacement, is the only indicator of true labor. Being a multipara, increased intensity and duration of contractions, and spontaneous rupture of membranes do not correlate as closely as the cervical changes.

The nurse is planning to teach a class of expectant parents about the cardinal movements, or changes in position, that occur as the fetus passes through the birth canal. The nurse plans to teach the positional changes in the sequence in which they occur when the fetus is in a cephalic presentation. Place the cardinal movements in the correct sequence. 1. Expulsion 2. External rotation 3. Flexion 4. Internal rotation 5. Restitution

Answer: 3, 4, 5, 2, 1 3. Flexion 4. Internal rotation 5. Restitution 2. External rotation 1. Expulsion Rationale: The cardinal movements (position changes) of the fetus occur in the order of engagement, descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. These movements represent the normal adaptation of the fetus in a cephalic presentation to the maternal pelvis and facilitate vaginal birth.

The neonate is crying, has a pink body with blue extremities, has flexed arms with clenched fists, heart rate of 154, and gags when the bulb suction is used. The nurse records the Apgar score to be _______. Provide an answer that is a whole number. Fill in your answer below: _______

Answer: 9 Rationale: Apgar scores are based on 0, 1, or 2 points in each of the five categories: respiratory effort, color, muscle tone, heart rate, and reflexes. This neonate would score 2 points in each category except color, where the presence of acrocyanosis would warrant a score of 1 point.