Ch 13 Evolve Questions

Nurses can advise their patients that which of these signs precede labor? (Select all that apply.) A. A return of urinary frequency as a result of increased bladder pressure B. Persistent low backache from relaxed pelvic joints C. Stronger and more frequent uterine (Braxton Hicks) contractions D. A decline in energy, as the body stores up for labor E. Uterus sinks downward and forward in first-time pregnancies.

A. A return of urinary frequency as a result of increased bladder pressure B. Persistent low backache from relaxed pelvic joints C. Stronger and more frequent uterine (Braxton Hicks) contractions After lightening a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term.

The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.) A. Positive urine drug screen B. Blood glucose level of 78 mg/dL C. Increased systolic blood pressure during first stage D. Elevated white blood cell count E. Oral temperature of 99.8° F F. Respiratory rate of 10 breaths/min

A. Positive urine drug screen C. Increased systolic blood pressure during first stage The health care provider should be alerted to a positive urine drug screen, because certain drugs will have an effect on pain medications that can be safely administered. The respiratory rate usually increases during labor. A rate of 10 is low and needs to be reported. Decreased blood glucose levels (due to exertion and glucose consumption for energy), and increased systolic blood pressure, elevated white blood cell count (due to stress response), and a slightly elevated temperature (up to 100.4° F) are expected findings during labor.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A. The fetal presenting part is 1 cm above the ischial spines. B. Effacement is 4 cm from completion. C. Dilation is 50% completed. D. The fetus has achieved passage through the ischial spines.

A. The fetal presenting part is 1 cm above the ischial spines. ation of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.) A. passenger. B. placenta. C. passageway. D. psychologic response. E. powers. F. position.

A. passenger. C. passageway. D. psychologic response. E. powers. F. position. At least five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: A. progressive uterine contractions with cervical change. B. lightening. C. rupture of membranes. D. passage of the mucous plug (operculum).

A. progressive uterine contractions with cervical change. Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours C. Lull: no contractions; dilation stable; duration of 20 to 60 minutes D. Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

B. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

Concerning the third stage of labor, nurses should be aware that: A. the placenta eventually detaches itself from a flaccid uterus B. the duration of the third stage may be as short as 3 to 5 minutes C. it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface D. the major risk for women during the third stage is a rapid heart rate

B. the duration of the third stage may be as short as 3 to 5 minutes A. The placenta cannot detach itself from a flaccid (relaxed) uterus. B. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. C. Which surface of the placenta comes out first is not clinically important. D. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? A. Semirecumbent B. Sitting C. Squatting D. Side-lying

C. Squatting A. A semirecumbent position does not assist in increasing the size of the pelvic outlet. B. Although sitting may assist with fetal descent, this position does not increase the size of the pelvic outlet. C. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. D. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet.

The nurse knows that the second stage of labor, the descent phase, has begun when: A. the amniotic membranes rupture. B. the cervix cannot be felt during a vaginal examination. C. the woman experiences a strong urge to bear down. D. the presenting part is below the ischial spines.

C. the woman experiences a strong urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: A. weight gain of 1 to 3lbs. B. quickening. C. fatigue and lethargy. D. bloody show.

D. bloody show. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct. Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: A. the woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. B. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C. having the woman point her toes reduces leg cramps. D. the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.

D. the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of potentially unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. D. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain.