Chapter 8: The Labor Process

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?

A. "She is in active labor; she is progressing at this point and we will keep you posted." B. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." C. "She is still in early latent labor and has much too long to go to tell when she will give birth." D. "She is doing well and is in the second stage; it could be anytime now."

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?

A. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." B. "This is not normal unless you are in active labor; come to the hospital and be checked." C. "That is something we expect with a second or third baby, but because it is your first, you need to be checked." D. "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."

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign?

A. "This is just a way of determining your progress in labor." B. "This indicates that you start labor within the next 24 hours." C. "This means +1 and the baby is entering the true pelvis." D. "The presenting part is at the true pelvis and is engaged."

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?

A. 0 to 2 B. 5 to 7 C. 3 to 4 D. 8 to 10

The nurse is preparing to teach a group of soon-to-be new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?

A. Breech B. Shoulder C. Oblique lie D. Transverse lie

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? A. Continue to monitor the progress of labor. B. Auscultate fetal heart rate (FHR) in the left upper quadrant. C. Prepare the client for cesarean birth of the fetus. D. Educate the client this fetal position may result in a longer labor.

A. Continue to monitor the progress of labor. B. Auscultate fetal heart rate (FHR) in the left upper quadrant. C. Prepare the client for cesarean birth of the fetus. D. Educate the client this fetal position may result in a longer labor.

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

A. Fetal station B. Fetal attitude C. Fetal position D. Fetal size

The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately?

A. Increment B. Acme C. Decrement D. Relaxation

A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. What report by the client would lead the nurse to predict the woman is close to labor?

A. Nesting B. Dilation C. Effacement D. Ripening of the cervix

When documenting the fetus is at "zero station", the nurse knows this is where in relation to the pelvic structure?

A. Pelvic inlet B. Pelvic outlet C. Ischial spines D. Pelvic crest

A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?

A. Reassuring; it is associated with normal acid-base balance. B. Worrisome; it may be associated with metabolic acidosis. C. Critical; it represents metabolic acidosis. D. Damaging; it is frequently associated with fetal neurological damage.

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?

A. Tell the woman to stay home until her membranes rupture. B. Emphasize that food and fluid should stop or be light. C. Ask the woman to describe why she believes that she is in labor. D. Arrange for the woman to come to the hospital for labor evaluation.

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?

A. The client is in active labor. B. The duration of the contractions is every 5 minutes. C. The frequency of the contractions is every 5 minutes. D. The client can be sent home.

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?

A. The contraction pains are 2 minutes apart and 1 minute in duration. B. The client reports back pain, and the cervix is effacing and dilating. C. The contraction pains have been present for 5 hours, and the patterns are regular. D. After walking for an hour, the contractions have not fully subsided.

The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor?

A. The infant needs to be assessed by the health care provider. B. Ecchymosis indicates a blood disorder and the infant will need testing. C. Ecchymosis with edema on the scalp is where the infant was pushed out of the canal. D. Edema is swelling and caused by unusual trauma; the provider must have used forceps.

A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?

A. contractions, irregular, lasting 15 to 20 seconds B. bloody mucus in the toilet once earlier in the day C. contraction, regular and lasting longer and stronger D. scant amount of thick, white vaginal discharge, no odor

The nursing instructor is teaching a session on the birth process. During which stage does the woman's cardiac output increase 80% above the pre-labor level?

A. first stage B. pushing C. immediately after birth D. transition stage

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

A. flexion B. engagement C. extension D. expulsion

A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lb (43 kg), and has gained 25 lb (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment?

A. gynecoid B. platypelloid C. android D. cannot be determined

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?

A. increase even if relaxing and taking a shower B. remain irregular with the same intensity C. subside when walking around and use the lateral position D. cause discomfort over the top of uterus

The nurse is appraising the post-birth laboratory results of a client and discovers the WBC is 22,000 cells/μL (22 x 109/L). Which action should be prioritized in response?

A. none, a normal variation due to labor B. an abnormal finding, needs antibiotics C. occurs in clients after a cesarean birth D. further testing is required to determine source.

A group of nursing students are preparing a presentation that will illustrate various components of the birthing process. When discussing the pelvis, the students should point out that the pelvis is often referred to as which term?

A. passenger B. passageway C. powers D. psyche

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?

A. solid food and fluids B. nothing except for intravenous fluids C. clear liquids but no solid food D. cannot assess with the information given

The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? A. transition B. second C. third D. active

A. transition B. second C. third D. active

The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?

A. transition phase B. stage two C. latent phase D. stage three