Chapter 8: The Labor Process

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 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.

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?

Molding 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 nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready At the station +4, 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, the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean section is not needed as the fetus has progressed through the birth canal.

After pelvic measurements, a patient 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?

Passageway Passageway focuses on the size and contour of the pregnant patient'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 patient's ability to view labor as a positive experience.

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most?

positive reinforcement Any woman, even one who has taken natural childbirth classes, has a difficult time maintaining positive coping strategies during this phase of labor. Many women describe feeling out of control during this phase of labor. A woman in transition needs support, encouragement, and positive reinforcement.

During the second stage of labor, a woman is generally:

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 client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?

uterus becomes globular 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.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

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.

The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?

Head flexed forward so much that the chin touches the sternum A fetus in good attitude is in complete flexion: the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. This usual "fetal position" is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible. The other attitudes listed are not ideal, because larger diameters of the fetus' skull are presenting.

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?

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.

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 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.

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?

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 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. 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 description is best when documenting an accurate client contraction?

The client's contractions are 5 minutes apart and last 45 seconds. It is best to document a client's contraction using the following terms: frequency of contractions, duration and intensity. Using the pain scale describes the intensity of the contraction. A contraction lasting 30 seconds documents duration. A contraction 5 minutes apart lasting 45 seconds documents frequency and duration. Having a client who cries documents a client's psyche.

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. 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?

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

Which nursing action would the nurse anticipate doing more often for a cesarean section newborn than a vaginal birth newborn?

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.

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?

degree of thinning 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 student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:

descent, flexion, internal rotation, extension, external rotation, expulsion The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.

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?

duration 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 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.

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted?

gynecoid The most favorable pelvic shape for vaginal birth is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth, but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?

poorly ossified bones of the cranial vault Molding is an adaptive process in which there is overriding and movement of the bones of the cranial vault to adapt to the maternal pelvis. The poorly ossified bones of the cranial vault, along with loosely attached membranous attachments, allow for the process of molding in the fetal skull. The bones of the face and the base of the skull are completely ossified and united. Hence they cannot allow for movement or overriding. The membranous attachments are loosely (not tightly) bound to the cranial vault, which allows for molding of the fetal skull.

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?

Fetal lie Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.

Which statement made by the client in the early phase of labor requires clarification?

"I have been at 3 cm for hours and I am making no progress." It is important for the mother to understand that even though she is not dilating, other important parts of labor such as effacement are occurring. Women vary in length of time during each stage and phase of the labor process. Nurses and clients hope that all labors are better than the previous. Typically the labors are shorter but that is not guaranteed. In early labor, the contractions are manageable and walking is appropriate.

During a prepared childbirth class, the nursing is discussing the differences between true and false labor. Which responses by a client indicate an understanding of false labor? Select all that apply.

"Maintaining hydration by drinking water will lessen false labor pains." "The intensity of contractions is inconsistent in false labor." False labor is a phenomena that occurs in the later weeks of pregnancy. During false labor, the woman may experience contractions. These contractions may vary in intensity. They do not become regular nor do they increase in intensity. Activity such as walking can increase contraction strength and frequency during true labor, but walking does not increase the manifestations of false labor. Remaining hydrated is important. Dehydration may result in uterine irritability and false labor pains. False labor pains are felt in the abdomen; in contrast, true labor contractions begin in the back and radiate to the front of the abdomen. Pelvic pressure increases during true labor.

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." 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.

Which nursing action has a negative effect on fetal descent?

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.

When measuring the diagonal conjugate of a woman's pelvis, the distance between which of the following anatomic landmarks would be used?

Anterior surface of the sacral prominence and the anterior surface of the symphysis pubis The diagonal conjugate measures the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis, or the anterior-posterior diameter of the pelvic inlet.

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 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 is no consensus of what actually happens to initiate the onset of labor. It is thought to be a combination of maternal and fetal factors that occur in such a way that labor begins. What is the term used to describe the way maternal and fetal factors interact to cause labor to begin?

Cascade effect Because a single causative factor of labor initiation has not yet been determined, the most likely answer seems to be that labor results from a combination of maternal and fetal factors working together in a cascade effect. During the cascade, factors that inhibit contractions, such as progesterone, are suppressed; and factors that promote contractions, such as prostaglandins, are engaged (Norwitz, 2006).

Which cardinal movement of delivery is the nurse correct to document by station?

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.

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?

Is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis.

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.

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 nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours?

"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, remember most women are aware of the word dilation (dilatation) but not effacement. Just saying, "no further dilation", therefore, 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.

When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche?

"You had a successful labor and vaginal delivery with your first pregnancy." Reminding the client of her successful labor and birth best provides confidence, which strengthens a woman's psyche. It is true that subsequent pregnancies are typically shorter in length, and input in the labor plan by the multipara client can be expressed (since the woman has already experienced the process), but these are not as important as successfully completing the process. Depending upon the client's past experiences, the intensity of the contractions may or may not be more intense.

The nurse is teaching a non-English speaking primigravida about the most common type of fetal presentation. Which presentation will the nurse prepare?

Cephalic presentation using preprinted materials in her language The most common presentation type is the cephalic presentation, and it is most appropriate to highlight the information using preprinted materials in her own language. Both portions of this answer are best. With pictures, the nurse can communicate on a common level and then the woman has the opportunity to review as needed. The breech and cephalic presentations are not the most common presentations. The footling is not a presentation.

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

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

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.

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage 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.

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?

Radiates from the back to the front 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.

A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor and the passage of the fetus through the birth canal. As part of the class, the nurse explains that specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse identify as being most important in affecting the birth process? Select all that apply.

Suboccipitobregmatic Biparietal The diameter of the fetal skull is an important consideration during the labor and birth process. Fetal skull diameters are measured between the various landmarks of the skull. Diameters include occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal. The two most important diameters that can affect the birth process are the suboccipitobregmatic (approximately 9.5 cm at term) and the biparietal (approximately 9.25 cm at term) diameters. Diagonal conjugate is a measure of the pelvic inlet of the mother.

A nurse is describing the events of labor to a group of pregnant women. Put the following events of labor as the nurse would explain them from first to last. All options must be used.

The cervix dilates to 2 cm. Cervix becomes fully effaced. Fetus continues descent. Crowning occurs. Placenta separates. Placenta is expelled. The events of labor occur in this order: 1) the cervix dilates to 2 cm, 2) cervix becomes fully effaced, 3) fetus continues descent, 4) crowning occurs, 5) placenta separates, and 6) placenta is expelled.

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions. The nurse identifies a priority during the active and transitional stage 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 is under 7 in the active and transitional phases. Walking in the hall and tolerating liquids also depends on the client.

The nurse is teaching a pregnant patient the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor?

The fetal head bends forward onto the chest. The cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation, and expulsion. In descent, the fetal head bends forward onto the chest once the head presses on the sacral nerves at the pelvic floor. The fetal head rotates into a transverse position prior to expulsion. The head extends so that the face and chin are born during extension. The shoulders move into an anteroposterior position during external rotation.

The nurse is preparing to assess the duration of contractions for a patient in labor. Which process should the nurse use to time the contractions?

The interval between the beginning and the end of one contraction To determine the beginning of a contraction without a monitor, rest a hand on a woman's abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. This is the duration. Contractions are not timed by measuring the number of contractions in 5 minutes, the end of one contraction to the beginning of the next, or by using the interval between the acmes of two consecutive contractions.

A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group, the nurse determines that the teaching was successful based on which statement by the group?

The pelvic outlet is associated with the true pelvis. The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

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 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.

Which change in client status suggests that labor is anticipated?

The woman can breathe easier throughout the day. Symptoms that the woman is able to breathe easier strongly suggest lightening. Lightening means that the fetus has dropped into the pelvis or is engaged. Typically when the fetus is in the pelvis, it impinges on the bladder causing the need for more frequent urination. Braxton Hicks contractions are the first contractions which may be present for some time. These contractions occur but can diminish when walking or when position changes. Anxiety and anticipation is commonly felt throughout pregnancy.

During which phase of labor would the nurse anticipate providing the most emotional support for the mother?

Transition phase of labor The transition phase of labor is the most difficult. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation (dilatation). The contractions at this point are strong and lasting 60 to 90 seconds. It is important for the nurse to help the woman through this stage and encourage her to rest between contractions.

Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.

Vaginal rugae stretch and smooth out The cervix dilates to 10 cm The cervix softens 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 give discomfort in the antepartal period.

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?

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.

After learning that her fetus is in the LST position, the client asks the nurse what this means. Which structure will the nurse point out is presenting first?

buttocks The second letter indicates the presenting part. The letter "S" indicates the sacrum or buttocks as the presenting part. The fetal head would be noted by the letter "O," indicating occiput. The fetal chin would be noted by the letter "M," indicating mentum. The fetal shoulder would be noted by the letter "A," indicating the acromion process. The first letter indicates the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The last letter specifies whether the presenting part is facing the anterior (A) or posterior (P) portion of the maternal pelvis or whether it is in a transverse (T) position.

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?

cervical dilation (dilatation) 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.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document?

completion of the third stage of labor The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. 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 mother (1 to 4 hours after birth). Within this fourth stage, the attachment process begins with the mother inspecting the newborn and desiring to cuddle and breastfeed the newborn.

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?

frank In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

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 client has not received any medication during her labor. She is having frequent contractions about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:

late active phase of the first stage of labor. Late in the active phase of labor, contractions become more frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies (moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in the serious work of her labor. She limits interactions with those in the room. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of the second stage is the period of active pushing. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta

Assessment of a woman 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:

latent phase of the first stage. 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 mother. 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?

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.

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?

rupture of amniotic membranes The nurse should identify the rupture of amniotic membranes as the best indicator of approaching labor. In labor, the client experiences increased vaginal secretions, increased duration of contractions, and also loss of mucus plug.

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 bloody show backache 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 woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom?

moderately strong contractions every 4 minutes, lasting about 1 minute 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?

occiput 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.

A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?

part of the fetal body entering the maternal pelvis first The term presentation is the part of the fetal body that is entering the maternal pelvis first. The relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. The relation of the fetal presenting part to the maternal ischial spine is termed the station.

When educating a group of nursing students about the different types of pelvis, 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?

platypelloid 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, ischial spine is somewhat prominent, and the sacrum is inclined posteriorly.