Chapter 13: Labor and Birth Process (Prep U)

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? squatting while holding her breath lying supine with legs in lithotomy stirrups head elevated, grasping knees, breathing out lying on side, arms grasped on abdomen

head elevated, grasping knees, breathing out An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? +2 +4 -2 0

-2 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 primigravida has an office appointment at 39 weeks' gestation. Which assessment data is most definitive of the onset of labor? Expulsion of the mucus plug. Cervical ripening is noted on examination. The fetal head is engaged in the pelvis. The mother reports frequent urination.

Cervical ripening is noted on examination. Clinical signs that labor is approaching include ripening or softening of the cervix with effacement and dilation (dilatation). Frequent urination is common during engagement where the fetal head is in the pelvis. This is common up to 2 weeks before true labor begins. Expulsion of the mucus plug also is common a week or two before labor begins.

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which of the following is an advantage of adopting a kneeling position during labor? It helps to rotate the fetus in a posterior position. It helps the woman in labor to save energy. It facilitates external belt adjustment. It facilitates vaginal examinations.

It helps to rotate the fetus in a posterior position. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.

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? Third First Second Fourth

Third Stage three begins with the birth of the baby and ends with delivery of the placenta.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? rupturing of fetal membranes diffuse abdominal cramping start of regular contractions dilation (dilatation) of cervix diameter to 10 cm

dilation (dilatation) of cervix diameter to 10 cm The first stage of labor terminates with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.

Which nursing action would the nurse anticipate doing more often for a cesarean section newborn than a vaginal birth newborn? Upper airway suctioning Monitor the temperature Assess voiding Note number of stools

Upper airway suctioning The newborn from the cesarean section 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 baby's number of stools.

The five "Ps" of labor are: passenger, position, powers, presentation, psych. passenger, posture, position, presentation, psych. passenger, position, presentation, pushing, psych. passageway, passenger, position, powers, psych.

passageway, passenger, position, powers, psych. The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Maternal request for pain medication Maternal heart rate and blood pressure The station in which the fetus is located Fetal heart rate in relation to contractions

Fetal heart rate in relation to contractions 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.

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? increased risk of breech presentation potential rapid birth of fetus increased risk of infection potential placenta previa

increased risk of infection After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response? "It is a measurement to determine if the pelvis size is adequate for a vaginal birth." "It is the measurement between the ischial tuberosity and the pubis." "It is the smallest diameter of the pelvic outlet." "It is the largest diameter of the pelvic outlet."

"It is a measurement to determine if the pelvis size is adequate for a vaginal birth." Since the obstetric conjugate cannot be measured directly, the practitioner must estimate the size. To obtain this estimate, the practitioner measures the diagonal conjugate, which extends from the symphysis pubis to the sacral promontory.

During which time is the nurse correct to document the end of the third stage of labor? At the time of placental delivery When pushing begins When the mother is moved to the postpartum unit Following fetal birth

At the time of placental delivery 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.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Admission time and time of fetal birth Time of mucus plug expulsion and full cervical dilation Complete cervical dilation (dilatation) and time of fetal birth Effacement time and time when contractions are regular

Complete cervical dilation (dilatation) and time of fetal birth The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.

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 Transverse Obtuse

Longitudinal 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.

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 is in the true pelvis and engaged. The fetus is floating high in the pelvis. The fetus has descended down the birth canal. The client is fully effaced.

The fetus is in the true pelvis and engaged. 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.

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." "She is still in early latent labor and has much too long to go to tell when she will give birth." "She is doing well and is in the second stage; it could be anytime now." "She is in active labor; she is progressing at this point and we will keep you posted."

"She is in active labor; she is progressing at this point and we will keep you posted." At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.

The nurse is caring for a nullipara client at 40 weeks' gestation. After assessing the client, the health care provider states that the fetus is at a -4 station. Which statement by the client requires clarification by the nurse? "The health care provider states my labor is imminent." "I hope that the end of my pregnancy will be uneventful." "I will go home and pack my bag and await the labor process to begin." "The health care provider will reassess me next week, if I make it."

"The health care provider states my labor is imminent." With the fetus at a -4 station, the fetus is floating above the true pelvis and unengaged. The fetus will need to engage in the pelvis for labor to begin. While the fetus can engage at any time, labor is not imminent. It is true that the client is on weekly health care provider appointments. The fetus is able to engage in the true pelvis, providing the opportunity to have a typical vaginal delivery. It is appropriate at 40 weeks' gestation to have a bag packed to come to the hospital when labor begins.

The nurse is providing care to a pregnant woman in labor. Which components would be assessed when evaluating the passageway? Select all that apply. Uterine contractions. Abdominal muscle contractions Fetal skull Bony pelvis Cervical soft tissues

Bony pelvis Cervical soft tissues The passageway consists of the woman's bony pelvis and the soft tissues of the cervix and vagina. Uterine contractions and abdominal muscle contractions are the powers. Fetal skull is a component of the passenger.

Which cardinal movement of delivery is the nurse correct to document by station? Extension Descent Internal rotation Flexion

Descent 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.

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? Notify the client's support person that the labor is typically long. Take no extra measures; prepare for a standard labor. 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. 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.

A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? A woman should be allowed to assume a supine position. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. Women should be able to move about freely throughout labor. Routine intravenous fluid should be implemented.

Women should be able to move about freely throughout labor. Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.

When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories? decrease in prostaglandins, leading to myometrium contractions decrease in number of oxytocin receptors decrease in the level of estrogen change in estrogen-to-progesterone ratio

change in estrogen-to-progesterone ratio One of the theories suggests that labor is initiated by a change in the estrogen-to-progesterone ratio. The number of oxytocin receptors have been noted to increase. Estrogen levels also increase, which in turn increases myometrial sensitivity to oxytocin. Prostaglandin levels also increase, which in turn leads to myometrial contractions.

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? restitution engagement descent crowning

crowning Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.

A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply. fresh gushing of blood from the vagina umbilical cord descending lower down a globular shaped uterus falling downward of uterus in the abdomen a relaxed and distended uterus

fresh gushing of blood from the vagina umbilical cord descending lower down a globular shaped uterus The signs of placental separation include a fresh gush of blood from the vagina, lengthening of the umbilical cord, and a globular shape to the uterus. When the client is in her third stage of labor, these indicate placental separation. A rising upward of the uterus and a well-contracted globular uterus are the other signs of placental separation. Falling downward of the uterus in the abdomen and a relaxed uterus are the signs of uterine atony.

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? cause discomfort over the top of uterus increase even if relaxing and taking a shower subside when walking around and use the lateral position remain irregular with the same intensity

increase even if relaxing and taking a shower True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? decreased plasma fibrinogen levels increased blood coagulation time increased white blood cell count increased blood glucose levels

increased white blood cell count The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.

A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: relieved by walking. occurring about every 5 minutes. occurring in the abdomen and groin. lasting about 30 seconds.

occurring about every 5 minutes. The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.

The nurse is working triage in the emergency department. The nurse realizes the client is in true labor when she states that the she is experiencing: contractions. fetal engagement. expelling mucus plug. ruptured membranes.

ruptured membranes. The nurse realizes that the client is in true labor when her membranes spontaneously rupture. At this point, the woman is transferred to the labor and delivery unit. Fetal engagement and expelling the mucus plug may occur a week before true labor begins. Contractions may or may not indicate true labor.

During the second stage of labor, a woman is generally: turning inward to concentrate on body sensations. no longer in need of a support person. anxious to have people around her. very aware of activities immediately around her.

turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? "That is something we expect with a second or third baby, but because it is your first, you need to be checked." "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital." "This is not normal unless you are in active labor; come to the hospital and be checked."

"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress? "There has been no further dilatation; effacement is progressing." Don't mention anything to the client yet; wait for further dilatation to occur. "You are still 2 cm dilated, but the cervix is thinning out nicely." "You haven't dilated any further, but hang in there; it will happen eventually."

"You are still 2 cm dilated, but the cervix is thinning out nicely." Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilatation but not effacement. Therefore, just saying, "no further dilatation" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? -5 0 +1 +4

+4 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.

Which nursing action has a negative effect on fetal descent? Walking the client in the hall Administering narcotic pain medication Laying the client on the left side Using a tap water enema

Administering narcotic pain medication Narcotic 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 narcotic 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.

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 cause "ripening" of the cervix. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions get closer together with activity.

Braxton Hicks contractions usually decrease in intensity with walking. 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? Perineum Uterus Cervix False pelvis

Cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4, three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry? Cannot assess with the information given Nothing except for intravenous fluids Clear liquids but no solid food Solid food and fluids

Clear liquids but no solid food The nurse should offer clear liquids but no solid foods. She is moving closer to active labor nearing the end of the latent phase. It would not be advisable to offer her solid foods, but she needs to continue her nourishment with fluids to her thirst. Solid foods may lead to nausea and vomiting. Intravenous fluids are too extreme as long as she is able to drink.

In which manner is the fetal status best assessed during the active and transition stages of labor? Fetal heart rate at the peak of a contraction Fetal kicks over a 1-minute period Fetal movement on the tocometer Fetal heart rate between contractions

Fetal heart rate at the peak of a contraction Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best indicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother? Absence of testicular rugae Significant head molding Single palmar crease Thick vernix

Significant head molding 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.

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 Oxytocin Prostaglandins Testosterone Thyroxine Insulin

Oxytocin Progesterone Prostaglandins 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? ROA LOA LOP ROP

ROA 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.

The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? Reduce the rate of cesarean births among low-risk women. Ensure all couples receive preconception genetic counseling. Encourage women with previous cesareans to always have a cesarean. Ensure care during labor includes immunizations.

Reduce the rate of cesarean births among low-risk women. Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? The contraction pains have been present for 5 hours, and the patterns are regular. After walking for an hour, the contractions have not fully subsided. The contraction pains are 2 minutes apart and 1 minute in duration. The client reports back pain, and the cervix is effacing and dilating.

The client reports back pain, and the cervix is effacing and dilating. True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? The client can be sent home. The frequency of the contractions is every 5 minutes. The duration of the contractions is every 5 minutes. The client is in active labor.

The frequency of the contractions is every 5 minutes. Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.

The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with which? The passageway The psyche The powers The passenger

The powers One of the four "P's" is the power of the uterine contractions. This power begins with regular contractions which become closer together and increase in intensity. The powers push the fetus down the birth canal.

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? a cephalohematoma wrapping of the head a caput succedaneum developmental delay

a cephalohematoma Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. Instructions for care include simple observation of the area. The cephalohematoma will subside in a couple of weeks and may take a couple of months to completely go away. There is no brain damage associated with a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure? promoting the woman's feelings of control providing clear information about procedures encouraging the woman to use relaxation techniques allowing the woman time to be alone

allowing the woman time to be alone Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.

When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanel (fontanelle). Which description would the nurse include? approximately 2 to 3 cm in size closes 8 to 12 weeks after birth triangular shape located at the back of the fetal head

approximately 2 to 3 cm in size The anterior fontanel (fontanelle) measures about 2 to 3 cm in size, is diamond-shaped, and closes 12 to 18 months after birth. The posterior fontanelle is triangular and located at the back of the fetal head. The posterior fontanelle closes about 8 to 12 weeks after birth.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds? relaxin oxytocin prostaglandins catecholamines

catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

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 occiput presentation using a PowerPoint presentation cephalic presentation using preprinted materials in the client's language breech presentation using a picture

cephalic presentation using preprinted materials in the client's language 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.

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? dilation (dilatation) molding effacement crowning

effacement 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 determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: duration. frequency. peak. intensity.

frequency. Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. increase in blood pressure increase in gastric emptying and pH increase in heart rate slight decrease in body temperature increase in respiratory rate

increase in heart rate increase in blood pressure increase in respiratory rate When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in systolic blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

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? presentation lie attitude position

lie 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 client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: placenta previa. rupture of the membranes. start of labor. lightening.

lightening. Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor. It is a premonitory sign of labor and is not associated with rupture of membranes or placental previa.

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? progesterone relaxin prolactin oxytocin

relaxin As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? shortening of the upper uterine segment restoration of blood flow to uterus and placenta reduction in length of the cervical canal effacement and dilation (dilatation) of the cervix

restoration of blood flow to uterus and placenta The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation (dilatation) of the cervix are other processes that occur during uterine contractions.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? breech vertex cephalic shoulder

shoulder The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.