EXAM #2 - CHP 16 QUESTIONS

The nurse is instructing a primigravida that the definitive sign indicating that labor has begun is which event? A. Progressive uterine contractions with cervical change B. Lightening C. Rupture of membranes D. Passage of the mucus plug (operculum)

A. Progressive uterine contractions with cervical change

A nurse is completing an admission assessment for a client who is 39 weeks of gestations and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum Hemorrhage D. Hydraminos

B. Infection

Which education would the nurse provide when describing lightening to a primigravida client? A. It occurs when true labor is in progress. B. It allows the client to breathe more easily. C. It decreases pressure on the bladder. D. It leads to decreased urinary frequency.

B. It allows the client to breathe more easily.

Which fetal presentations are visible during birth? Select all that apply. A. Breech B. Oblique C. Cephalic D. Shoulder E. Transverse

A. Breech C. Cephalic D. Shoulder

In which stage of labor would the nurse expect the placenta to be expelled? A. First B. Second C. Third D. Fourth

C. Third

Which signs and symptoms preceding labor would the nurse assess with a client who is 38 weeks pregnant? Select all that apply. A. Loss of weight B. Pain in the groin C. Persistent low backache D. Loss of energy E. Blood-tinged cervical mucus

A. Loss of weight B. Pain in the groin C. Persistent low backache E. Blood-tinged cervical mucus

Which statement by the nurse is accurate when the infant's presenting part is the sacrum in a near-term pregnant client? A. "Vaginal delivery may not be possible." B. "There will be no complications during labor." C. "You may have to lose weight for a safe delivery." D. "The infant may have congenital physical defects."

A. "Vaginal delivery may not be possible."

Which condition places the pregnant client at a higher risk for a cesarean delivery? A. A client with the fetus in a transverse lie B. A client with the fetus in a cephalic presentation C. A client with the fetal biparietal diameter of 9.25 cm at term D. A client in whom the presenting part is 4 cm below the spines

A. A client with the fetus in a transverse lie

Which fetal and maternal physiologic conditions would the nurse assess during the first stage of labor? Select all that apply. A. Fetal heart rate B. Fetal circulation C. Maternal heart rate D. Maternal Valsalva maneuver E. Maternal supine hypotension

A. Fetal heart rate B. Fetal circulation C. Maternal heart rate

Which statement by the student nurse regarding the cervix indicates effective learning? A. "The cervix allows fetal descent into the vagina." B. "The cervix is the external opening of the vagina." C. "The cervix allows the fetus to rotate anteriorly." D. "The cervix distends and accommodates the intrauterine contents."

A. "The cervix allows fetal descent into the vagina."

Which signs of preceding labor would the nurse teach an antepartum client? 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 E. Uterus sinks downward and forward in first-time pregnancies

Which signs precede the onset of labor? Select all that apply. A. A return of urinary frequency, because 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. Weight loss of 0.5 to 1.5 kg

A. A return of urinary frequency, because of increased bladder pressure B. Persistent low backache, from relaxed pelvic joints C. Stronger and more frequent uterine (Braxton Hicks) contractions E. Weight loss of 0.5 to 1.5 kg

Which statements are accurate regarding the course of labor without complications? Select all that apply. A. A single fetus presents by vertex. B. It is completed within 8 hours. C. A regular progression of contractions, effacement, dilation, and descent occurs. D. A regular progression of uterine contractions occurs. E. Mechanisms of labor are involved.

A. A single fetus presents by vertex. C. A regular progression of contractions, effacement, dilation, and descent occurs. D. A regular progression of uterine contractions occurs. E. Mechanisms of labor are involved.

A G5/P4 is experiencing painful contractions that start in her back every 10 minutes for the last hour. How would the telephone triage nurse advise this woman? A. Advise the patient to report to the hospital for labor and delivery. B. Tell the patient to call an ambulance. C. Instruct the woman to come to the hospital when the contractions are every 5 minutes. D. Inform the patient that she is experiencing Braxton Hicks contractions.

A. Advise the patient to report to the hospital for labor and delivery.

Which assessment finding in the client increases the risk for cephalopelvic disproportion (CPD)? A. Android pelvis B. Effacement of the cervix C. Biparietal diameter of 9.25 cm D. Involuntary uterine contractions

A. Android pelvis

The nurse is completing a history and physical on an obstetric client who is in early labor. Which factors would concern the nurse regarding a successful vaginal delivery? Select all that apply. A. Biparietal diameter of less than 9.25 cm B. Vertex presenting part C. Transverse lie D. General flexion attitude E. Android pelvis

A. Biparietal diameter of less than 9.25 cm C. Transverse lie E. Android pelvis

Which factors affect the process of labor and birth? Select all that apply. A. Birth canal B. Endogenous endorphins C. Contractions D. Blood glucose levels E. Fetus and placenta

A. Birth canal C. Contractions E. Fetus and placenta

Which are the different parts of the true pelvis? Select all that apply. A. Brim B. Outlet C. Android D. Midpelvis E. Anthropoid

A. Brim B. Outlet D. Midpelvis

Which factors would the nurse discuss with a client about the effect of secondary powers during labor? A. Contractions are expulsive in nature. B. Intraabdominal pressure is decreased. C. Contractions move downward in waves. D. Contractions begin at pacemaker points.

A. Contractions are expulsive in nature.

Which are functions of the primary powers in the labor process? Select all that apply. A. Dilation of the cervix B. Descent of the fetus C. Effacement of the cervix D. Raise the pain threshold E. Expulsion of the infant from the uterus

A. Dilation of the cervix C. Effacement of the cervix E. Expulsion of the infant from the uterus

A woman with an epidural is 10 cm dilated and the baby is at 0 station. There is a reassuring fetal heart pattern, although the woman does not feel the urge to push. Which are appropriate actions by the nurse? A. Encourage the patient to wait to push until she feels the urge. B. Perform another vaginal examination to check for dilation C. Encourage the patient to push so that the baby can be born D. Encourage frequent position changes while remaining in the bed E. Turn off the epidural so the patient can feel the urge to push

A. Encourage the patient to wait to push until she feels the urge. D. Encourage frequent position changes while remaining in the bed

Which are the cardinal movements of labor for a vertex presentation delivery? A. Engagement, descent, flexion, internal rotation, extension, and restitution B. Internal rotation, flexion, extension, descent, restitution, and engagement C. Internal rotation, descent, extension, flexion, restitution, and engagement D. Engagement, restitution, flexion, internal rotation, extension, and restitution

A. Engagement, descent, flexion, internal rotation, extension, and restitution

A woman is visibly anxious, refuses position changes in labor, and verbalizes, "I'm afraid I'm going to die." The nurse knows it is important to help the woman relax through effective coaching because of which responses to stress experienced in labor? A. Fetal intolerance to labor B. Bradycardia related to a vagal response C. Release of catecholamines in the mother's body D. Inhibited uterine contractions because of decreased blood flow to the placenta E. Umbilical cord prolapse

A. Fetal intolerance to labor C. Release of catecholamines in the mother's body D. Inhibited uterine contractions because of decreased blood flow to the placenta

A nurse is caring for a client having contractions every 8 minutes that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% faced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor

A. First stage, latent phase

Which factors would affect the onset of labor? Select all that apply. A. Increasing intrauterine pressure B. Increasing estrogen levels C. Decreasing oxytocin levels D. Decreasing progesterone levels E. Decreasing prostaglandin levels

A. Increasing intrauterine pressure B. Increasing estrogen levels D. Decreasing progesterone levels

The nurse is teaching a primigravida client about the signals that indicate the beginning of labor. Which is a sign that labor is beginning? A. Involuntary contractions B. Pain in the pelvic joints C. 100% effacement of the cervix D. Full dilation of the cervix

A. Involuntary contractions

The nurse palpates the fontanels and sutures to determine the fetal presentation. Which is the characteristic of the anterior fontanel? A. It is diamond-shaped in appearance. B. It measures about 1 cm by 2 cm. C. It closes after 6 to 8 weeks of birth. D. It lies near the occipital bone.

A. It is diamond-shaped in appearance.

The nurse is assessing a client in labor and documents the progress in effacement of the cervix and little increase in descent. Which phase of labor is the client in? A. Latent phase B. Active phase C. Transition phase D. Descent phase

A. Latent phase

During a sterile vaginal examination, the nurse finds that the fetal position is ROA. Which is the presenting part of the fetus? A. Occiput B. Sacrum C. Scapula D. Mentum

A. Occiput

The charge nurse on the maternity unit is teaching a new nurse about the five Ps that affect labor and birth. Which five factors would the nurse include in the teaching? Select all that apply. A. Passenger B. Placenta C. Passageway D. Psychological response E. Powers F. Position

A. Passenger C. Passageway D. Psychological response E. Powers F. Position

Which are common signs that the nurse would teach a client to observe in the days preceding labor? Select all that apply. A. Persistent low backache B. Increase in lethargy C. Blood-tinged vaginal mucus D. Increase in weight up to 1.5 kg E. Profuse vaginal mucus

A. Persistent low backache C. Blood-tinged vaginal mucus E. Profuse vaginal mucus

The nurse understands that which hormonal changes are thought to encourage the onset of labor? A. Rising estrogen counteracts the relaxing effect of progesterone on the uterus. B. Follicle-stimulating hormone is secreted in large quantities by the anterior pituitary. C. Prostaglandins are secreted by the fetal membranes preparing the uterus. D. The fetus secretes cortisol, which may act as an additional uterine stimulant. E. Thyroid-stimulating hormone is enhanced and helps make the uterus contractile. F. Oxytocin is secreted by the mother, which causes uterine contractions.

A. Rising estrogen counteracts the relaxing effect of progesterone on the uterus. C. Prostaglandins are secreted by the fetal membranes preparing the uterus. D. The fetus secretes cortisol, which may act as an additional uterine stimulant. F. Oxytocin is secreted by the mother, which causes uterine contractions.

Which are factors that accelerate dilation of the cervix? Select all that apply. A. Strong uterine contractions B. Scarring of the cervix C. Pressure by amniotic fluid D. Prior infection of the cervix E. Force by fetal presenting part

A. Strong uterine contractions C. Pressure by amniotic fluid E. Force by fetal presenting part

The nurse is caring for a postpartum client after a vaginal birth. The client is concerned about the shape of the infant's head. Which factors would the nurse include in responding to the client? Select all that apply. A. The bones of the skull continue to grow after birth. B. The shape of the head undergoes molding during labor. C. The head assumes its normal shape within 1 month. D. The skull bones of an infant are generally firmly united. E. The sutures and fontanels make the skull flexible.

A. The bones of the skull continue to grow after birth. B. The shape of the head undergoes molding during labor. E. The sutures and fontanels make the skull flexible.

Which fetal attitudes are present in general flexion? Select all that apply. A. The chin is flexed on the chest. B. The legs are flexed at the knees. C. The fetal head is extended. D. The thighs are flexed on the abdomen. E. The arms are crossed over the thorax.

A. The chin is flexed on the chest. B. The legs are flexed at the knees. D. The thighs are flexed on the abdomen. E. The arms are crossed over the thorax.

Which is an abnormal finding in a fetus during labor? A. The fetal heart rate is 190 beats/min at term. B. The fetal head is in a synclitic position. C. The fetal oxygen pressure decreases. D. The fetal circulation is decreased.

A. The fetal heart rate is 190 beats/min at term.

After completion of a vaginal examination on a laboring client, the nurse records: 50%, 6 cm, -1. Which 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.

The client is in the third trimester of pregnancy and reports pain in the pelvic joints. The nurse knows that the pain is caused by which factor? A. There is relaxation of the pelvic joints. B. There is decreased mobility of the ligaments. C. The joint of the symphysis pubis is narrowing. D. The pelvis may not support vaginal birth.

A. There is relaxation of the pelvic joints.

Which statement describes the primary powers of labor? A. These involuntary movements are responsible for effacement and dilation of the cervix and fetal descent. B. Dilation generally is well ahead of effacement in women giving birth for the first time; they are less together in subsequent pregnancies. C. Scarring of the cervix caused by a previous infection or surgery may make delivery a bit more painful, but it should not slow or inhibit dilation. D. The voluntary movements of pushing are more effective if the client can breathe deeply and control some of her actions.

A. These involuntary movements are responsible for effacement and dilation of the cervix and fetal descent.

How is effacement measured? A. Through digital palpation by a trained professional B. Using transvaginal ultrasound C. By estimating the stage of labor D. Though palpation of cervical dilation E. Through Leopold maneuvers

A. Through digital palpation by a trained professional B. Using transvaginal ultrasound

Which passenger position would interfere with a safe vaginal birth? A. Transverse fetal lie B. Flexed fetal head C. Cephalic presentation D. Longitudinal fetal lie

A. Transverse fetal lie

Which is the most appropriate time to determine the station of the presenting part in a pregnant client? A. When the labor begins B. One week before the labor C. During the fourth stage of labor D. At the end of the third stage of labor

A. When the labor begins

When assessing a client for the possibility of a vaginal delivery, which factor regarding the coccyx would the nurse keep in mind about the bony pelvis? A. It is the part above the brim of the bony pelvis. B. It is movable in the latter part of the pregnancy. C. It has three planes: the inlet, midpelvis, and outlet. D. It is ovoid and bound by the pubic arch anteriorly.

B. It is movable in the latter part of the pregnancy.

Occiput posterior refers to which component of the birth process? A. Powers B. Passenger C. Passage D. Psyche

B. Passenger

Which shape is the classic female pelvis shape and most conducive to a vaginal labor and delivery? A. Android B. Gynecoid C. Platypelloid D. Anthropoid

B. Gynecoid

The nurse instructor is teaching a group of students about the structure of the fetal head during labor and birth. Which statement by the student indicates effective learning? A. The fetal skull bones are firmly united during labor." B. "The fetal skull bones are united by membranous sutures." C. "The two important fontanels are the parietal and temporal." D. "The sutures and fontanels restrict brain growth after delivery."

B. "The fetal skull bones are united by membranous sutures."

During the vaginal examination of a laboring client, the nurse assesses that the fetus is in the right occiput anterior (ROA) position at -1 station. Which position is the lowermost portion of the fetal presenting part? A. 2 cm above the ischial spine. B. 1 cm above the ischial spine. C. 2 cm below the ischial spine. D. 1 cm below the ischial spine.

B. 1 cm above the ischial spine.

What would the nurse expect when caring for a full-term primigravida who presents for a routine office visit and is not in labor? A. A fundal height that measures 30 cm B. A fetus that is engaged in the maternal pelvis C. A cervix that is already 3 cm dilated D. Fetal station of −3

B. A fetus that is engaged in the maternal pelvis

The nurse is informing a client regarding the distinctive stages of labor. Which descriptions of the phases of the first stage of labor are accurate? Select all that apply. 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 E. Full cervical dilation marks the end of the first stage of labor

B. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours E. Full cervical dilation marks the end of the first stage of labor

Which neurologic change would the nurse expect in assessing the laboring client? A. Decreased pain threshold B. Amnesia and sedation C. Increased perception of pain D. Client is elated between contractions

B. Amnesia and sedation

The nurse is performing a prenatal pelvic examination of a client and knows which pelvic type is least favorable for a vaginal birth? A. Gynecoid B. Android C. Anthropoid D. Platypelloid

B. Android

A woman at 37 weeks gestation calls and reports, "My water broke and I have bloody show. I am changing my pad every 10 minutes." Which advice would the nurse provide in response? A. Engage in activity such as walking. B. Call her health care provider and go to the hospital or birthing center. C. Advise the woman that overreacting is not good for her or the baby and to call back when she is in "true labor." D. Remain home, and only come in to the hospital or birthing center if contractions are regular, frequent, and intense.

B. Call her health care provider and go to the hospital or birthing center.

A nurse is caring for a client who is 40 weeks of gestation and reports having large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A. Examine the amniotic fluid for meconium B. Check the FHR C. Dry the client and make the comfortable D. Apply a tocotransducer

B. Check the FHR

The nurse is providing care during labor for a client with twins and instructs the client to avoid lying flat on the back. Which condition would the nurse aim to prevent in the client during labor? A. Valsalva maneuver B. Supine hypotension C. Respiratory alkalosis D. Painful uterine contractions

B. Supine hypotension

Which statement is accurate regarding caring for a client in the third stage of labor? A. The placenta eventually detaches itself from a flaccid uterus. B. The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered. 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 of labor is rapid heart rate.

B. The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered.

The nurse knows that many factors can affect fetal circulation during labor. Which factors would affect fetal circulation during labor? Select all that apply. A. Fetal presentation B. Uterine contractions C. Blood pressure D. Umbilical cord blood flow E. Fetal sex

B. Uterine contractions C. Blood pressure D. Umbilical cord blood flow

The nurse recognizes that the patient understands the teaching when she makes which statement? A. "Premonitory labor signs include rupture of membranes." B, "I will know I'm in labor when I lose my mucous plug." C. "Increasing clear vaginal secretions could mean labor will begin soon." D. "Bright red bleeding is considered bloody show and means labor will begin soon."

C. "Increasing clear vaginal secretions could mean labor will begin soon."

A postpartum client is worried because her newborn's head is not round. The delivery documentation indicates that the newborn had molding on delivery. What is the nurse's best response? A. "The infant will look better after more hair grows." B. "The infant's skull must be massaged after a month." C. "The infant's head will assume a normal shape in 3 days." D. "Some infants have an oddly shaped head, which is alright."

C. "The infant's head will assume a normal shape in 3 days."

Which action taken by the patient will reduce discomfort during Leopold maneuvers and make fetal presenting parts easier to feel? A. Standing B. Lying prone C. Emptying the bladder D. Pushing or bearing down with contractions

C. Emptying the bladder

The nurse is caring for a client in the first stage of labor and notes that the client has scarring on her cervix as a result of a past STI. Which complication would the nurse predict in the client during labor? A. Ferguson reflex B. Slow fetal descent C. Supine hypotension D. Slow cervical dilation

D. Slow cervical dilation

The nurse assisting a laboring client recognizes the Ferguson reflex in a client. Which is the most accurate description of the Ferguson reflex? A. Release of endogenous oxytocin B. Involuntary uterine contractions C. Maternal urge to bear down D. Mechanical stretching of the cervix

C. Maternal urge to bear down

The nurse would anticipate which client condition in the second stage of labor? A. The amniotic membranes rupture. B. The cervix cannot be felt during a vaginal examination. C. The client experiences a strong urge to bear down. D. The presenting part is below the ischial spines.

C. The client experiences a strong urge to bear down.

Explain what the term fetal presentation is when assessing a fetus in cephalic presentation? A. The relation of the presenting part to the mother's pelvis B. The relation of the fetus's and mother's spine C. The part of the fetus that enters the pelvic inlet first D. The relation of the fetal body parts to one another

C. The part of the fetus that enters the pelvic inlet first

A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomit and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth stage C. Transition phase D. Latent phase

C. Transition phase

When caring for a client in labor, which instruction would the nurse provide in the second stage of labor? A. "Point your toes to prevent pain." B. "Avoid fluids until the infant is delivered." C. "Lie still and avoid movement to prevent fatigue." D. "Avoid holding your breath or tightening the abdominal muscles."

D. "Avoid holding your breath or tightening the abdominal muscles."

A woman who is at 38 weeks gestation reports suspected signs of labor to the triage nurse. Which statement by the nurse supports the beginning of true labor? A. "Your contractions will decrease with activity." B. "The contractions will be mild and more annoying than painful." C. "You will feel the contractions in your front pelvic area and not in your back." D. "Labor contractions will occur in a consistent pattern that increases in frequency, duration, and intensity."

D. "Labor contractions will occur in a consistent pattern that increases in frequency, duration, and intensity."

Which statement by the student nurse regarding the different stages of labor indicates effective learning? A. "There is no abnormal bleeding in the first stage of labor." B. "The placenta is delivered in the fourth stage of labor after the birth." C. "Full effacement and dilation of the cervix indicates the beginning of the second stage." D. "The second stage lasts from full dilation of the cervix to the birth of the fetus."

D. "The second stage lasts from full dilation of the cervix to the birth of the fetus."

Which is the best response by the nurse to a client who complains of the urge to have a bowel movement during each contraction? A. "There is a possibility of an infection." B. "I will have to evaluate your urine reports." C. "There is a complication with the delivery." D. "This is a normal occurrence at the onset of labor."

D. "This is a normal occurrence at the onset of labor."

Which statement by the nurse is accurate when the client's sonogram indicates that the fetus has a cephalic presentation? A. The fetal skull is not flexible." B. "There are fetal complications." C. "You may need a cesarean delivery." D. "Vaginal delivery will be the best choice."

D. "Vaginal delivery will be the best choice."

The nurse assisting a laboring client is aware that the birth of the fetus is imminent. Which is the appropriate station of the presenting part? A. -1 B. +1 C. +3 D. +5

D. +5

Which is the optimal suboccipitomental diameter for a laboring client with a fetus in brow presentation? A. 9.25 cm B. 9.5 cm C. 12.0 cm D. 13.5 cm

D. 13.5 cm

In which stage would the nurse expect the fetal head to be engaged in the pelvic inlet for a multiparous client? A. Before term at 2 weeks B. Before the start of active labor C. When labor stage 1 begins D. After labor is established

D. After labor is established

Which is a sign of impeding labor the nurse would describe to a primigravida client? A. Weight gain of 1 to 3 lbs B. Quickening C. Fatigue and lethargy D. Bloody show

D. Bloody show

The ultrasound report of a pregnant client reveals extreme asynclitism of the fetal head. Which would the nurse anticipate may result based on the findings from this report? A. The fetal head is parallel to the anteroposterior plane of the pelvis. B. The client will have a normal vaginal delivery. C. The position of the fetal head will facilitate descent. D. Cephalopelvic disproportion will be seen during labor.

D. Cephalopelvic disproportion will be seen during labor.

A patient reports a feeling of lightness in her abdomen, increasing whitish, thin, and odorless vaginal discharge, and occasional contractions that go away after an hour or so. Which action would the nurse take next? A. Advise the patient to report to the birthing center. B. Suggest routine sexual transmitted infection counseling. C. Call the ambulance because she is experiencing an emergency. D. Educate the patient on the premonitory signs of labor.

D. Educate the patient on the premonitory signs of labor.

Which nursing intervention is most important when providing care for a pregnant client in the first stage of labor? A. Determining the station B. Obtaining a prescription for epidural anesthesia C. Encouraging the client to hold her breath and tighten the abdominal muscles D. Encouraging the client to change position frequently

D. Encouraging the client to change position frequently

During a prenatal evaluation, the nurse notes that the client has a flat pelvis. Which term would the nurse use in documenting the findings? A. Gynecoid B. Android C. Anthropoid D. Platypelloid

D. Platypelloid

During the vaginal examination of a client in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation would the nurse recognize? A. Cephalic B. Frank breech C. Complete breech D. Shoulder

D. Shoulder

When assessing the health of a client during labor, the nurse would be aware of which physiologic change? A. The client's blood pressure increases during contractions and falls back to prelabor baseline between contractions. B. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C. Having the client point her toes will reduce the occurrence of leg cramps. D. The endogenous endorphins released during labor raise the client's pain threshold and produce sedation.

D. The endogenous endorphins released during labor raise the client's pain threshold and produce sedation.

A pregnant woman arrives at the emergency department, and after completing a vaginal examination the nurse midwife states that the patient is 5 cm dilated and 75% effaced and the fetus is at −3 station. Which statement is accurate regarding this assessment? A. The patient may initiate pushing efforts. B. The cervix is fully dilated. C. The cervix is fully effaced. D. The fetus is not engaged within the maternal pelvis.

D. The fetus is not engaged within the maternal pelvis.

A client calls a provider's office and reports having contractions for 2 hours that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions

D. True contractions

With regard to fetal positioning during labor, nurses should be aware that: a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b. Birth is imminent when the presenting part is at +4 to +5 cm, below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d. Engagement is the term used to describe the beginning of labor.

b. Birth is imminent when the presenting part is at +4 to +5 cm, below the spine.