PNE 136 / Maternity / PrepU Chapter 8
The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? Oblique Longitudinal Obtuse Transverse
Longitudinal Explanation: The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie. In the transverse lie, the fetus lies crosswise to the maternal spine. An oblique lie is between the two. There is not an obtuse lie.
After pelvic measurements, a client who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this? powers psychological outlook passenger passageway
passageway Explanation: Passageway focuses on the size and contour of the pregnant client's pelvis. Passenger addresses the size, position, and presentation of the fetus. Powers determine if uterine factors for labor are adequate. Psychological outlook focuses on the pregnant client's ability to view labor as a positive experience.
Which nursing action would the nurse anticipate doing more often for a cesarean birth newborn than a vaginal birth newborn? Monitor the temperature. Assess voiding. Note the number of stools. Suction the upper airway.
Suction the upper airway. Explanation: The neonate born via cesarean birth will need more upper airway suctioning as the newborn did not have the maternal contractions squeeze the fluid from the lung fields. There is no change is assessing temperature, voiding, and the number of stools.
A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through." "It is elongated, the width is roomy, but the length is narrow." "It is rounded in shape and allows ample room for the neonate to fit through the passageway."
"It is rounded in shape and allows ample room for the neonate to fit through the passageway."
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? fetal presenting part degree of thinning passage of the mucous plug extent of opening to its widest diameter
degree of thinning Explanation: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
A client is in the third stage of labor. Which finding alerts the nurse that the placenta is separating? mucous plug is expelled uterus becomes globular fetal head at vaginal opening umbilical cord shortens
uterus becomes globular Explanation: Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Time of mucus plug expulsion and full cervical dilation Effacement time and time when contractions are regular Admission time and time of fetal birth Complete cervical dilation (dilatation) and time of fetal birth
Complete cervical dilation (dilatation) and time of fetal birth Explanation: The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
During the second stage of labor, a woman is generally: turning inward to concentrate on body sensations. very aware of activities immediately around her. no longer in need of a support person. anxious to have people around her.
turning inward to concentrate on body sensations. Explanation: Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? "I feel the tightening primarily in the front of my belly." "I will have a strong one and then the next one will be weaker." "The contractions lessen after I drink a large glass of water." "I feel pressure in my vagina when I have the contraction."
"I feel pressure in my vagina when I have the contraction." Explanation: True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? -2 +4 0 +2
-2 Explanation: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A fetus at 0 (zero) station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.
A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? "I will have a strong one and then the next one will be weaker." "I feel pressure in my vagina when I have the contraction." "I feel the tightening primarily in the front of my belly." "The contractions lessen after I drink a large glass of water."
"I feel pressure in my vagina when I have the contraction." Explanation: True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.
During a visit to the prenatal clinic, a pregnant woman asks the nurse, "What causes labor to start?" Which response by the nurse would be appropriate? "Labor starts when the uterus can't grow any further." "Labor starts from a combination of several maternal and fetal hormones working together." "Just before labor, the level of the hormone oxytocin drops." "Labor starts when the fetus moves into the pelvis."
"Labor starts from a combination of several maternal and fetal hormones working together." Explanation: There are several hypotheses regarding what causes labor to begin. A single causative factor of labor has not yet been determined. Studies indicate labor onset results from a combination of several maternal and fetal hormones working together. Fetal movement and uterine size are not associated with the onset of labor. A rise in oxytocin has been suggested as playing a role.
A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why." Which response by the nurse would be most appropriate? "You were looking forward to the birth of your baby." "You were trying to get everything ready for your baby." "You felt your mind telling you that you were about to go into labor." "You had a burst of epinephrine, which is common before labor."
"You had a burst of epinephrine, which is common before labor." Explanation: Some women report a sudden increase in energy before labor. This is sometimes referred to as nesting because many women will focus this energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household. The increased energy level usually occurs 24 to 48 hours before the onset of labor. It is thought to be the result of an increase in epinephrine (adrenaline) release caused by a decrease in progesterone. The burst of energy is unrelated to getting everything ready, the mind telling the woman that she will be going into labor, or looking forward to the birth.
A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate? "Your cervix thins so that your contractions can increase." "Cervical thinning is a sign that you are in true labor." "It thins to let your baby change positions during labor." "You need the cervix to thin so it can stretch more easily."
"You need the cervix to thin so it can stretch more easily." Explanation: The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? +4 0 +1 -5
+4 Explanation: As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
During which time is the nurse correct to document the end of the third stage of labor? When pushing begins Following fetal birth At the time of placental delivery When the mother is moved to the postpartum unit
At the time of placental delivery Explanation: The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions cause "ripening" of the cervix. Braxton Hicks contractions get closer together with activity.
Braxton Hicks contractions usually decrease in intensity with walking. Explanation: Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? Cervix False pelvis Uterus Perineum
Cervix Explanation: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
Which cardinal movement of delivery is the nurse correct to document by station? Extension Internal rotation Flexion Descent
Descent Explanation: Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? The station in which the fetus is located Maternal heart rate and blood pressure Fetal heart rate in relation to contractions Maternal request for pain medication
Fetal heart rate in relation to contractions Explanation: The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? Fetal attitude Fetal presentation Fetal position Fetal lie
Fetal lie Explanation: Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.
Which nursing action is a priority when the fetus is at the +4 station? Prepare for an immediate cesarean birth. Have a tocometer and a client gown ready. Have a blue bulb suction and an infant warmer ready. Provide lubricating jelly and an internal monitor.
Have a blue bulb suction and an infant warmer ready. Explanation: At +4 station, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission, the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation (dilatation), the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean birth is not needed as the fetus has progressed through the birth canal.
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? Caput succedaneum Cephalohematoma Molding Vertex presentation
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.
Which is the most important nursing assessment of the mother during the fourth stage of labor? The mother's psyche Heart rate Hemorrhage Blood pressure
Hemorrhage Explanation: During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.
The nurse is assessing a client for rupture of membranes. Which findings would confirm the presence of ruptured membranes? Select all that apply. Ferning is present. The client reports having wet pants. A pool of fluid is visible in the vagina. The cervix is effaced. Nitrazine paper turns blue.
Nitrazine paper turns blue. Ferning is present. A pool of fluid is visible in the vagina. Explanation: The three signs to confirm rupture of membranes are visible pool of fluid in the vagina, blue nitrazine test resulting from the alkaline amniotic fluid, and ferning present on microscopic examination. The client's report of wet pants is not diagnostic of ruptured membranes. Effacement of the cervix begins prior to the onset of labor and before the rupture of membranes.
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. Progesterone Thyroxine Testosterone Insulin Oxytocin Prostaglandins
Progesterone Oxytocin Prostaglandins Explanation: There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
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? LOP LOA ROA ROP
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.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? Lasts about 20 to 25 seconds Occurs in an irregular pattern Slows when the woman changes position Radiates from the back to the front
Radiates from the back to the front Explanation: Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? Take no extra measures; prepare for a standard labor. Notify the client's support person that the labor is typically long. Anticipate this client is a one-to-one registered nursing assignment. Prepare for vital signs and fetal monitoring hourly.
Take no extra measures; prepare for a standard labor. Explanation: The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid inlet allows the fetus room to pass through the dimensions of the bony passageway. Therefore, the nurse does not need to take any extra measures nor is there a reason to expect that labor will take a long time. Anticipating the client will need one-to-one nursing and preparing for vital signs and fetal monitoring hourly is not indicated. These measures can be instituted should an issue arise.
Which client outcome during the active phase labor is best? The client will state a pain level of 7 or less during contractions. The client will tolerate 8 oz (240 ml) of clear liquids. The client will walk in the hall for 15 minutes every 2 hours. The client will practice breathing techniques during contractions.
The client will practice breathing techniques during contractions. Explanation: The nurse identifies a priority during the active phase of labor as working with the contractions to give birth. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level will be less than 7 in the active phase. Walking in the hall and tolerating liquids also depends on the client.
The nurse is preparing to perform a straight catheterization on a client in labor. What assessment data support this nursing action? The fetus is noted to be a breech presentation. Trace amounts of protein are found in the urine. The urine-specific gravity tests at as higher than expected. The fetal head is not descending as expected.
The fetal head is not descending as expected. Explanation: A full bladder puts pressure on the lower uterine segment and prevents the head from descending. In this situation, the health care provider may prescribe a straight catheter (in-and-out catheter) to empty the bladder and allow labor to progress. Trace amounts of protein in the urine is noted with the increased metabolic activity noted with labor, but this finding would not be a reason for urinary catheterization. The client may have concentrated urine, and therefore, an elevated specific gravity, but again, this finding is not a reason to insert a urinary catheter. Breech presentation is uncommon, but if it occurs, it would not necessitate a straight catheterization.
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 fetus has descended down the birth canal. The client is fully effaced. The fetus is in the true pelvis and engaged. The fetus is floating high in the pelvis.
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 client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? First Third Fourth Second
Third Explanation: Stage three begins with the birth of the baby and ends with delivery of the placenta.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? Second First Third Fourth
Third Explanation: Stage three begins with the birth of the baby and ends with delivery of the placenta.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? Second First Fourth Third
Third Explanation: Stage three begins with the birth of the baby and ends with delivery of the placenta.
Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply. The cervix dilates to 10 cm. Round ligaments contract. The cervix softens. Vaginal rugae stretch and smooth out. Effacement is noted as 0%.
Vaginal rugae stretch and smooth out. The cervix dilates to 10 cm. The cervix softens. Explanation: Changes in the female body occur to allow the passage of the fetus down the birth canal. Vaginal rugae stretch and smooth out allowing for the ability of the fetus to descend. The cervix thins to a maximum of 10 cm and the cervix softens, becoming more accepting of the transition through by the fetus. Full effacement is noted as 100%. Round ligaments stretch to accommodate the expanding uterus and frequently result in discomfort in the antepartum period.
Which nursing action has a negative effect on fetal descent? laying the client on the left side administering opioid pain medication using a tap water enema walking the client in the hall
administering opioid pain medication Explanation: Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process. The opioid effect can provide the mother with a needed break and allow her to rest between contractions. The mother may lie in any position comfortable. Neither eliminating stool nor walking in the hall will slow fetal transport.
The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare? footling presentation drawing a hand-prepared diagram breech presentation using a picture cephalic presentation using preprinted materials in the client's language occiput presentation using a PowerPoint presentation
cephalic presentation using preprinted materials in the client's language Explanation: The most common presentation type is the cephalic presentation, and it is most appropriate to highlight the information using preprinted materials in the client's language. Both portions of this answer are best. With pictures, the nurse can communicate on a common level and then the client has the opportunity to review as needed. The breech and occiput presentations are not the most common types of fetal presentation. The footling is not a type of fetal presentation.
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? placental separation cervical dilation (dilatation) regular contractions fetal movement through the birth canal
cervical dilation (dilatation) Explanation: The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.
A nurse is providing care to a client in labor. The nurse determines that the client has moved into the active phase based on which assessment finding(s)? Select all that apply. contractions every 1 to 2 minutes strong desire to push contractions lasting up to 60 seconds cervical dilation (dilatation) of 6 cm cervical effacement of 80%
cervical dilation (dilatation) of 6 cm cervical effacement of 80% contractions lasting up to 60 seconds Explanation: During the active phase, the cervix usually dilates from 6 to 10 cm, with 40% to 100% effacement taking place. Contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). A strong desire to push signify the perineal phase of the second stage of labor.
The nurse is assisting a pregnatn client in labor and delivery and notes the placenta is now delivered. What will the nurse document? postpartum phase completion of the fourth stage of labor attachment phase completion of the third stage of labor
completion of the third stage of labor Explanation: The third stage of labor ends with the expulsion of the placenta. The fourth stage begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the pregnant client (1 to 4 hours after birth). The fourth stage initiates the postpartum phase. Within this fourth stage, the attachment process begins with the client inspecting the newborn and desiring to cuddle and breastfeed the newborn.
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? degree of thinning extent of opening to its widest diameter passage of the mucous plug fetal presenting part
degree of thinning Explanation: Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? intensity frequency peak duration
duration Explanation: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.
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 dilation (dilatation) crowning molding
effacement Explanation: The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.
The nurse is caring for a client in active labor. Which assessment finding requires health care provider notification? elevated WBC count hyperventilation gross proteinuria nausea
gross proteinuria Explanation: There are normal physiologic changes that occur during the labor process. Gross proteinuria is not anticipated and is a sign of a complication. The health care provider is notified. If hyperventilation occurs, the woman is encouraged to breathe into her cupped hands or a paper bag. An elevated white blood cell count is common due to the immune response. Nausea is common due to prolonged gastric emptying.
Assessment of a client 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: active phase of the first stage. latent phase of the first stage. early phase of the third stage. pelvic phase of the second stage.
latent phase of the first stage. Explanation: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the pregnant client. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? position presentation attitude lie
lie Explanation: The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
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 signs as an indication of starting labor? Select all that apply. lightening weight gain backache bloody show constipation
lightening backache bloody show Explanation: The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilation (dilatation). Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.
A client calls the health care facility stating that they are in labor. The nurse will urge the client to come to the facility if the client reports which symptom? 1) pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds 2) contractions noted in the front of the abdomen that stop when the client walks 3) increased energy level with alternating strong and weak contractions 4) moderately strong contractions every 4 minutes, lasting about 1 minute
moderately strong contractions every 4 minutes, lasting about 1 minute Explanation: Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? buttocks shoulders occiput brow
occiput Explanation: With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.
When educating a group of nursing students about the different types of pelves, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type? gynecoid anthropoid platypelloid android
platypelloid Explanation: A platypelloid pelvis is a flat pelvis with a wider transverse diameter than anterior-posterior diameter, ischial spines are wide apart, and the sacrum is short. In a gynecoid pelvis, the inlet is oval, the pubic arch is wide, it has dull ischial spines, and the sacrum has no anterior or posterior inclinations. In an android pelvis, the inlet is heart shaped, the ischial spines are prominent, and the sacrum is straight. In an anthropoid pelvis, the anterior-posterior diameter is longer than the transverse diameter, the ischial spine is somewhat prominent, and the sacrum is inclined
When going through the active phase of labor, clients often feel out of control. What intervention will help these clients best? their significant other beside them positive reinforcement just to be left alone intense nursing care
positive reinforcement Explanation: Any client, even one who has taken natural childbirth classes, has a difficult time maintaining positive coping strategies during the active phase of labor. Many clients describe feeling out of control during this phase of labor. A client in the active phase needs support, encouragement, and positive reinforcement.
Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother? thick vernix absence of testicular rugae significant head molding single palmar crease
significant head molding Explanation: Since this is the mother's first birth, the birth canal has never been stretched. The labor process may take longer and may be tighter leading to significant molding as the fetal body, particularly the head, molds to the mother's birth canal. Thick vernix and absence of testicular rugae are a characteristics of prematurity. Genetic conditions such as trisomy 13 have characteristics of a single palmar crease as one of the signs of the potential disorder.
