intrapartum Q&A

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous infusion rate.

1. An appropriate action by the doula is giving the woman a back massage. 2. An appropriate action by the doula is to assist the laboring woman with her breathing. The nurse, not the doula, should assess the fetal heart. The nurse, not the doula, should assess the blood pressure. The nurse, not the doula, should regulate the IV. TEST-TAKING TIP: Even if the test taker were unfamiliar with the role of the doula, he or she could deduce the answers to this question. Three of the responses involve physiological assessments or interventions, while two of the responses deal with providing supportive care—the role of the doula.

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1,000 mL of Ringer's lactate. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.

1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should receive an order to infuse Ringer's lactate before the woman is given regional anesthesia. 5. The nurse should ask the woman to empty her bladder. It is not appropriate to place the woman in the Trendelenburg position. The blood pressure will need to be monitored every 5 minutes for 15 minutes after administration of the anesthesia but not before.

In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider ordered self-administered inhaled nitrous oxide (N2O) in a N2O 50% / O2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? Select all that apply. 1. Nausea. 2. Hypotension. 3. Dehydration. 4. Light-headedness. 5. Late fetal heart decelerations.

1. Both nausea and vomiting are side effects of nitrous oxide administration. 4. Patients often do exhibit light-headedness when using N2O. When administered in a 50%/50% concentration, nitrous oxide has not been shown to cause hypotensive episodes. Patients using N2O are not at high risk for dehydration. One important advantage of N2O over other labor pain-relieving methods is the fact that the fetus, and the baby after birth, rarely exhibit adverse responses to the medication. TEST-TAKING TIP: Nitrous oxide is an important alternative to commonly used labor pain-relieving medications, that is, regional anesthesias and intravenous analgesics. The fact that it is self- administered enables the mother to determine when she needs the medication and when she wants to stop taking the medication. Once the gas is no longer inhaled, it takes about 5 minutes for the woman no longer to feel the effects of the gas

On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines. The fetal head is well past engagement. Engagement is defined as 0 station. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away. External rotation does not occur until after delivery of the fetal head TEST-TAKING TIP: This question includes a number of concepts. Descent and station are discussed in answer options 1 and 2. The dilation of the cervix, which is related to the fact that the woman is a primigravida, is discussed in choice 3. And one of the cardinal moves of labor— external rotation—is included in choice 4. The test taker must be prepared to answer questions that are complex and that include diverse information. In a 7 cm dilated primipara with a baby at +3 station, vaginal delivery is not imminent, but the fetal head is well past engagement and descent is progressing well. External rotation has not yet occurred because the baby's head has not yet been birthed.

A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization? 1. Syrian woman. 2. Chinese woman. 3. Russian woman. 4. Greek woman

1. Muslim women, who are often from Arabic countries, like Syria, are expected to keep their heads covered at all times. Chinese women do not usually request that their heads be covered. Russian women do not usually request that their heads be covered unless they are observant Jews. Greek women do not usually request that their heads be covered. TEST-TAKING TIP: There are two groups of women who are likely to request that their heads be covered at all times— observant Jews and observant Muslims. Many Arabic women are Muslim; therefore, the nurse should ask whether or not they would like head coverings. Observant or Orthodox Jewish women also will usually request that their heads be covered. It is very important that religious requests be met with acceptance by the healthcare staff.

Which of the following nonpharmacological interventions recommended by nurse midwives may help a client at full term to go into labor? Select all that apply. 1. Engage in sexual intercourse. 2. Ingest evening primrose oil. 3. Perform yoga exercises. 4. Eat raw spinach. 5. Massage the breast and nipples.

1. Nurse midwives sometimes recommend that women at full term engage in sexual intercourse to stimulate labor. 2. Ingesting primrose oil is also sometimes recommended. Primrose oil is believed to help ripen the cervix. 5.Nipple and breast massage is sometimes recommended to help induce labor. Exercise should be encouraged throughout pregnancy, but it is not used for induction. Raw spinach is an excellent source of iron as well as a source of calcium and fiber. It is, however, not used for induction. TEST-TAKING TIP: If the test taker were unfamiliar with nonpharmacological induction methods, he or she could make some educated guesses by remembering that pharmacological medications for labor induction are prostaglandins and oxytocin. When a woman has an orgasm during intercourse, she releases oxytocin. Nipple and breast massage also stimulate oxytocin production. Evening primrose oil contains a fatty acid that converts into a prostaglandin compound.

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate

1. Talking and laughing are characteristic behaviors of the latent phase. Back labor can be experienced during any phase of labor. Women in the latent phase often do perform effleurage, but it can also be performed during other phases of labor. A woman in the latent phase might go to the bathroom but defecating is not indicative of the first phase of labor. TEST-TAKING TIP: Although effleurage is a massage that women are taught to use during the latent phase of labor, it is important for the test taker to remember that women are individuals and are encouraged to use breathing techniques and other therapies that help them with their labors. Some women enjoy performing massage well into the active and transition phases and others never find it comforting.

The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station -2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

1. The cervix is thin. There is nothing in the scenario that suggests that the membranes are bulging. At −2 station, the head is well above the ischial spines. The cervix is dilated 5 cm (or approximately 2 inches). The nurse would, therefore, not feel a closed cervix. TEST-TAKING TIP: During pregnancy and early labor, the cervix is closed, long, and thick. During the labor process, however, the cervix changes shape, becoming paper thin and dilating to 10 cm. This is a universal finding. No matter how tall or short or old or young a woman is, her cervix will dilate to 10 cm and efface 100% if she has a vaginal delivery.

The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

1. The nurse's findings upon performing Leopold maneuvers indicate that the fetus is in the left occiput anterior (LOA) position—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the left sacral posterior (LSP) position; in that position, the fetus's buttocks (S or sacrum) are facing toward the mother's left posterior (LP), a hard round mass is felt in the fundal region, and a soft round mass is felt above the symphysis. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the right mentum anterior (RMA) position; in that position, the fetus's face (M or mentum) is facing toward the mother's right anterior (RA) and small objects are felt on the right of the mother's abdomen with a flat area felt on the mother's left side. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the right sacral posterior (RSP) position; in that position, the fetus's sacrum (S) is facing the mother's right posterior (RP) and a hard round mass is felt in the fundal region while a soft round mass is felt above the symphysis. TEST-TAKING TIP: The test taker must review fetal positioning. This is an especially difficult concept to understand. The best way to learn the three- dimensional concept of fetal position is to look at the pictures in a text. Using a doll, the nurse can then imitate the pictures by placing the doll into each of the positions.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions

1. The obstetric conjugate is the shortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head. When the fetal head is flexed, the diameter of the head is minimized. This is not, however, the obstetric conjugate. There is no average dilation for the beginning of labor. The physiological retraction ring is the area of the uterus that forms as a result of cervical effacement. It is not related to the obstetric conjugate. TEST-TAKING TIP: The obstetric conjugate is measured by the healthcare practitioner to estimate the potential for the fetal head to fit through the anterior-posterior diameter of the maternal pelvis. It is the internal distance between the sacral promontory and the symphysis pubis.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position

1. The relationship between the decelerations and the contractions will determine the type of deceleration pattern. The maternal blood pressure is not related to the scenario in the question. Although some fetuses are at higher risk for fetal distress, the nurse must first determine which type of deceleration is present. If the nurse is able to identify that a deceleration is present, the electrode placement is adequate. TEST-TAKING TIP: Decelerations are defined by their relationship to the contraction pattern. It is essential that the nurse determine which of the three types of decelerations is present. Early decelerations mirror contractions, late decelerations develop at the peak of contractions and return to baseline well after contractions are over, and variable decelerations can occur at anytime and are often unrelated to contractions.

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

1. The woman should be helped into the fetal position. The lithotomy position is inappropriate. The Trendelenburg position is inappropriate. The lateral recumbent position is inappropriate. TEST-TAKING TIP: For the anesthesiologist to be able to insert the epidural catheter into the epidural space, the woman must be placed in either the fetal position or sitting with her chin on her chest and her back convex. In both of those positions, the woman's vertebrae separate, providing the anesthesiologist access to the epidural space.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconium- stained fluid. The client needs to be assessed. Expelling the mucous plug is not sufficient reason to go to the hospital to be assessed The latent phase of labor can last up to a full day. In addition, Braxton Hicks contractions can last for quite a while. Even though a woman may feel cramping for 4 hours or more, she may not be in true labor. TEST-TAKING TIP: The mucous plug protects the uterine cavity from bacterial invasion. It is expelled before or during the early phase of labor. In fact, it may be hours, days, or even a week after the mucous plug is expelled before true labor begins

An ultrasound report states, "The fetal head has entered the pelvic inlet." How should the nurse interpret this statement? 1. The fetus is full term. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude

2. The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis. A full-term baby may still have yet to enter the pelvic inlet. The baby is physiologically unable to enter the true pelvis when in a horizontal lie. The attitude of the baby is not discussed in the ultrasound statement TEST-TAKING TIP: It is very important that the test taker be familiar with the many definitions that are used in obstetrics. If any of the definitions is unfamiliar, the test taker may be confused by some of the question stems or by the many answer options.

The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must the nurse perform at this time? 1. Place the client in the lateral recumbent position. 2. Carefully analyze the baseline data on the monitor tracing. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

2. The variability of the fetal heart rate is determined by analyzing the beat-to-beat fluctuations of the baseline rate. When assessing the variability of the fetal heart, the mother can be in any position. Only after assessing a poor fetal monitor tracing would the nurse administer oxygen.Variability is unrelated to fetal movement. TEST-TAKING TIP: There are many important principles related to electronic fetal heart monitoring. Variability is the most important of the baseline data. Variability is a measure of the competition between the sympathetic nervous system, which speeds up the heart rate, and the parasympathetic nervous system, which slows down the heart rate. When the fetal heart variability is adequate, the nurse can conclude, therefore, that the baby's autonomic nervous system is healthy

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary healthcare practitioner? 1. The woman is at high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is at high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2. The woman is in early labor. There is no need for her to be hospitalized at this time. The woman is exhibiting no high-risk issues. The woman is exhibiting no high-risk issues. The woman is in early labor, not active phase. TEST-TAKING TIP: The key facts that the test taker should attend to in this question about a primigravida are the cervical dilation, the contraction pattern, and the fetal heart pattern. The woman is clearly in the latent phase because she is only 2 cm dilated, is 30% effaced, and is contracting infrequently q 12 minutes with short duration. Plus, the fetal heart rate is excellent. She could be sent home to labor in comfort.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2. The woman's privacy should be maintained while she is resting. The woman should not push until the next contraction. She should be allowed to sleep at this time. The woman is in no apparent distress. Vital sign assessment is not indicated. The woman is in no apparent distress. Oxygen is not indicated. TEST-TAKING TIP: Because the woman is in second stage, she is pushing with contractions. If she is very tired, she is likely to fall asleep immediately following a contraction. It is important for the nurse to maintain the woman's privacy by covering her perineum with a sheet between contractions. It would also be appropriate to awaken the woman at the beginning of the next contraction.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

3. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis to birth the baby. It is recommended that women delay pushing until they feel the urge to push. 2. There is no indication for oxygen in this scenario. There is no indication of maternal compromise in this scenario. TEST-TAKING TIP: Although the use of an epidural is not high risk, there can be injuries to the maternal birth canal and/or the fetus when pushing is performed by a mother with no feeling. It is recommended that women who have lost all feeling because of an epidural "labor down," or rest and wait, until the urge to push returns. Once that happens, the woman should perform open glottal pushing during contractions.

The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing

3. Open glottal pushing is used during stage 2 of labor. The alternate pant-blow technique is used during stage 1 of labor. Rhythmic, shallow breaths are used during stage 1 of labor. Slow chest breathing is used during stage 1. TEST-TAKING TIP: Because the laboring client is in stage 2, the woman will change from using breathing techniques during contractions to pushing during contractions to birth the baby. Open glottal pushing is recommended because pushing against a closed glottis can decrease the mother's oxygen saturation

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Only during the peak of contractions. 4. For 1 minute immediately after contractions.

4. Intermittent auscultation should be performed for 1 full minute after contractions end The frequency of intermittent auscultation is determined by which stage of labor the woman is in. The frequency of intermittent auscultation is determined by which stage of labor the woman is in. The fetal heart rate should be assessed before, during and after contractions. TEST-TAKING TIP: Although most babies are monitored via electronic fetal monitoring in labor, there is a great deal of evidence to show that intermittent auscultation (AI) is as effective a method of monitoring the fetal heart. When performing AI, it is essential, however, that the fetal heart be monitored using a strict protocol: nurse caring for only one patient at a time who assesses the fetal heart before, during, and for at least 30 to 60 seconds immediately after contractions to monitor for the presence of any late or variable decelerations (see the Guideline for Fetal Heart Monitoring in Labor and Delivery (2012) published by the Northern New England Perinatal Quality Improvement Network)

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

4. Monitoring for rectal pressure is appropriate at this time. This client is fully dilated and effaced, but the baby is not yet engaged. Until the baby descends and stimulates rectal pressure, it is inappropriate for the client to begin to push. Fundal pressure is inappropriate. Many women push in the squatting position, but it is too early to push at this time. TEST-TAKING TIP: Although the test taker may see in practice that women are encouraged to begin to push as soon as they become fully dilated, it is best practice to wait until the woman exhibits signs of rectal pressure. Pushing a baby who is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing

4.This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time. It is inappropriate to encourage her to have an epidural at this time. It is inappropriate to encourage her to have an IV analgesic at this time. A change of position might help but will probably not be completely effective. TEST-TAKING TIP: If a woman has learned Lamaze breathing, it is important to support her actions. Encouraging her to take pain-relieving medications may undermine her resolve and make her feel like she has failed. The initial response by the nurse should be to support her by encouraging her to use her breathing techniques.

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA −1 station. 2. LSP −1 station. 3. LMP +1 station. 4. LSA +1 station

The LOA position refers to a fetus whose occiput (O) is facing toward the mother's left anterior (LA) and a presenting part at −1 station is 1 cm above the ischial spines. 2. The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and buttocks at −1 station are 1 cm above the ischial spines. 3. The LMP position refers to a fetus whose face (M or mentum) is facing toward the mother's LP and a presenting part at +1 is 1 cm below the ischial spines. 4. The LSA position refers to a fetus whose buttocks (S) are facing toward the mother's LA and a presenting part at +1 station is 1 cm below the ischial spines. TEST-TAKING TIP: If the test taker understands the definition of station, he or she could easily eliminate two of the four responses in this question. When the presenting part of the fetus is at zero (0) station, the part is at the same level as an imaginary line between the mother's ischial spines. When the presenting part is above the spines, the station is negative (-). When the presenting part has moved past the spines, the station is defined as positive (+). Because the question states that the nurse palpated the buttocks above the spines, the station is negative. This effectively eliminates the two answer options that include a positive sta

The healthcare practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV STAT for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? Calculate to the nearest hundredth. _____ mL

0.25 mL Standard formula for calculating the volume of medication to be administered: Known dosage : known volume = desired dosage : desired volume 2 mg : 1 mL = 0.5 mg : x mL 2 mg x = 0.5 mg x = 0.25 mL

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

1, 2 ,4 1.The nurse should assess the fetal heart before reporting the client's status to the healthcare provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 3. A complete urinalysis would likely be ordered by the primary healthcare practitioner once the client has been officially admitted, but the test would not be performed during the initial assessment process. 4.The nurse should assess the woman's vital signs before reporting her status. TEST-TAKING TIP: The fetal heart, contraction pattern, and maternal vitals all should be assessed to provide the healthcare practitioner with a picture of the health status of the mother and fetus. In some institutions, the nurse may also do a vaginal examination to assess for cervical change

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to. A bulging perineum indicates progression to the second stage of labor. The bloody show increases as a woman enters the second stage of labor. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. The gravida's ability to work with her labor is more dependent on her level of pain and her preparation for labor than on the phases and/ or stages of labor. TEST-TAKING TIP: It is important that the test taker clearly understands the difference between the three phases of the first stage of labor and the three stages of labor. The three phases of the first stage of labor—latent, active, and transition—are related to changes in cervical dilation and maternal behaviors. The three stages of labor are defined by specific labor progressions—cervical change to full dilation (stage 1), full dilation to birth of the baby (stage 2), birth of the baby to birth of the placenta (stage 3)

A pregnant woman is discussing possible delivery options with a labor nurse. Which of the following client responses indicates that the woman understood the information? Select all that apply. 1. When the client states, "I am glad that deliveries can take place in a variety of places, including in the labor bed." 2. When the client says, "I heard that for doctors to deliver babies safely, it is essential that I lie on my back with my legs up." 3. When the client states, "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." 4. When the client says, "During difficult deliveries it is sometimes necessary to put a woman's legs up in stirrups." 5. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position.

1, 3, 4, and 5 are correct. 1. This statement is true. A birth may take place in a variety of locations and positions, including sitting on a stool in the shower, kneeling while holding onto the back of the labor bed, or even while standing. 3 If the fetus is in the posterior or transverse position, the woman may be encouraged to push while on her hands and knees. This may enable the baby to turn into the anterior position and the delivery may soon follow. 4. Many mothers deliver in their labor beds without stirrups. Some beds transform into delivery beds and some are regular hospital beds. Still others are double or queen-sized beds so that the father and/ or the delivering practitioner can also relax in the bed. When forceps or other interventions are needed for a delivery, however, stirrups may be required. 5. Midwives deliver their clients in a variety of positions, including the side-lying, squatting, and lithotomy positions, as well as when the clients are on their hands and knees. The nurse should provide additional information to this client. Many deliveries are performed safely in positions other than the lithotomy position. TEST-TAKING TIP: Deliveries can be performed in a variety of positions, including lithotomy, squatting, and side-lying; in a variety of locations, including labor bed, delivery bed, toilet, shower, and in a dry environment or in water. It is recommended that mothers consult with their healthcare practitioners early in the pregnancy regarding the practitioner's delivery practices, including birth positions. The mother's birth preference may influence her choice of caregiver

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1,2,3,5 1. Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. 2.The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. 3.The client's age should also be noted before the physical assessment is begun. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth—should also be noted before a physical assessment is begun

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following side effects? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

1. Hypotension is a very common side effect of regional anesthesia. It is unlikely that the woman will experience adverse feelings in her lower extremities. The epidural does not enter the spinal canal. There will be no change, higher or lower, in the central venous pressure. Fetal heart accelerations are positive signs. These are not adverse findings. TEST-TAKING TIP: The test taker must be familiar with the side effects of all medications. If no other therapeutic interventions are performed, virtually all women will show signs of hypotension after epidural administration. The change is related to two phenomena: dilation of the vessels in the pelvis and compression of the vena cava.

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm

1. The nurse would expect the woman to be 2 cm dilated. At 4 cm, the woman is entering the active phase of labor. At 8 cm, the woman is in the transition phase of labor. At 10 cm, the woman is in the second stage of labor. TEST-TAKING TIP: In the latent phase of labor, clients are often very excited because the labor has finally begun. They frequently are very talkative and easily distracted from the discomfort of the contractions. The test taker should be familiar with the cervical changes that correlate with the various phases and stages of labor.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1. The tracing is showing a normal fetal heart tracing. No intervention is needed. There is no need to administer oxygen at this time. The tracing is normal. If the client is comfortable, there is no need to change her position.There is no need to speed up the intravenous at this time. TEST-TAKING TIP: The baseline fetal heart variability is the most important fetal heart assessment that the nurse makes. If the baby's heart rate shows average variability, the nurse can assume that the baby is not hypoxic or acidotic. In addition, the normal heart rate of 142 is reassuring.

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

1. This is a sign of placental separation. 3. This is a sign of placental separation. Once second stage is complete, the baby is no longer in utero. Dilation and effacement are complete before second stage begins. Rectal pressure is usually a sign of fetal descent. Once the second stage is complete, the baby is no longer in utero. TEST-TAKING TIP: It is essential that the test taker clearly differentiate between stage 1, stage 2, and stage 3 of labor. Stage 1, what is usually referred to as "labor," ends with full cervical dilation. At the end of stage 2, the baby is born. And at the conclusion of stage 3, the placenta is born.

A G1 P0, 8 cm dilated, is to receive pain medication. The healthcare practitioner has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesic. Which of the following medications would the nurse expect to be ordered in conjunction with the analgesic medication? 1. Seconal (secobarbital). 2. Phenergan (promethazine). 3. Stadol (butorphanol). 4. Tylenol (acetaminophen).

2. Phenergan acts to reduce nausea and vomiting as well as to reduce allergic response. Stadol is a narcotic analgesic. It would not be administered to a woman already receiving an analgesic. Tylenol is a nonsteroidal anti-inflammatory drug that is ineffective as an analgesic in labor. Seconal is a barbiturate sedative. It is not used as an analgesic potentiator. TEST-TAKING TIP: Phenergan has both antiemetic and antihistamine actions. It, as well as other medications like Reglan (metoclopramide) and Vistaril (hydroxyzine), helps to diminish the nausea associated with the analgesic and the vomiting associated with transition.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

2. This comment is consistent with a woman in the transition phase of stage 1. This comment would be consistent with a client in the latent phase of labor. This comment could be made at a variety of times during the labor. This comment is consistent with a woman in stage 2 labor. TEST-TAKING TIP: The test taker must be familiar not only with the physiological changes that occur during each phase of labor but also with the maternal behaviors that are expected at each phase.

Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? 1. Apply heat to the woman's back. 2. Inquire regarding the woman's pain level. 3. Make sure that the woman's head is covered. 4. Accept the woman's loud verbalizations.

2.It is important to inquire about the pain level of all women in labor, especially those from the Asian culture. Many Chinese believe that labor is a "hot" period. Applying heat at this time would be culturally insensitive. Head covering is important for observant Jewish women and Muslim women but is not usually important for Chinese women. It is very uncommon for Chinese women to be very verbal during labor. TEST-TAKING TIP: Childbearing and child rearing are fraught with cultural implications. It is essential that the nurse understand the many cultural beliefs of clients for whom they will care. Chinese women are often expected to be quiet during labor. Even when in severe pain, they often remain stoic and uncomplaining. It is essential, therefore, that the nurse repeatedly question them regarding their level of pain using an objective pain scale.

The physician writes the following order for a newly admitted client in labor: Begin a 1,000 mL IV of D5 1/2 NS at 150 mL/hr. The IV tubing states that the drop factor is 10 gtt/mL. Please calculate the drip rate to the nearest whole. _______ gtt/min

25 gtt/min Standard method formula for drip rate calculations: Volume in mL × Drop factor Time in minutes (150 mL/60 min) x 10 gtt/mL= 150/6 = 25 gtt/min TEST-TAKING TIP: Please note that when the units for each of the numbers is included, the test taker will never make a mistake with drip rate calculations because, as can be seen above, the mLs are cancelled out and what remains is the required units, gtt/min. Drip rates are always calculated to the nearest whole number because it is impossible to administer a fraction of a dro

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

3 During extension, the baby's head is birthed. Flexion is one of the first of the cardinal moves of labor. Internal rotation occurs while the baby is still in utero. The baby rotates externally after the birth of the head. TEST-TAKING TIP: The baby must move through the cardinal moves because the fetal head is widest anterior-posterior but the fetal shoulders are widest laterally. On the other hand, the maternal pelvis is widest laterally in the inlet but anterior- posterior at the outlet

During the third stage of labor, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts. 4. The uterine surface area dramatically decreases.

3, 4, 1, 2 3. The contraction of the uterus after delivery of the baby is the first step in the third stage of labor. 4. As the uterus contracts, its surface area decreases more and more. 1. A hematoma forms behind the placenta as the placenta separates from the uterine wall after the uterus has contracted and its surface area has decreased. 2. The membranes separate from the uterine wall after the placenta separates and begins to be born. 67. 1 and 3 are correct. 66. 1. TEST-TAKING TIP: Once the baby is born, the uterus contracts. When it does so, the surface area of the internal uterine wall decreases, forcing the placenta to begin to separate. As the placenta separates, a hematoma forms behind it, further promoting placental separation. Once the placenta separates and begins to be born, the membranes peel off the uterine wall and are delivered last

The nurse is providing acupressure for pain relief to a woman in labor. Where is the best location for the acupressure to be applied? Select all that apply. 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. At the top one-third of the sole of the foot. 5. Below the medial epicondyle of the elbow.

3. Pressure applied on the medial surface of the lower leg has been shown to lessen the pain of labor. 4. Pressure applied to the depression at the top one-third of the sole of the foot has been shown to lessen the pain of labor. The malleolus of the wrist has not been shown to reduce the pain of labor contractions. The area above the patella of the knee has not been shown to reduce the pain of labor contractions. The area below the elbow has not been shown to reduce the pain of labor contractions. TEST-TAKING TIP: Complementary therapies have been shown to be of value in a number of clinical situations, including labor. The specific acupressure point on the leg is located about 3 cm above the inner malleolus in the calf region. Acupressure has been shown to reduce the pain of labor contractions.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head. Breathing will help with contraction pain but is not as effective when a client is experiencing back labor. It is inappropriate automatically to encourage mothers to have anesthesia or analgesia in labor. There are other methods of providing pain relief. Hydrotherapy is very soothing but will not provide direct relief. TEST-TAKING TIP: Whenever a laboring woman complains of severe back labor, it is very likely that the baby is lying in the occiput posterior position. Every time the woman has a contraction, the head is pushed into the coccyx. When direct pressure is applied to the sacral area, the nurse is providing counteraction to the pressure being exerted by the fetal head.

A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

3.Analgesics are central nervous system (CNS) depressants. The variability of the fetal heart rate, therefore, will be decreased. The baby's heart rate should not exhibit variable decelerations after the mother is given pain-relieving medication. The baby's heart rate should not exhibit late decelerations after the mother is given an analgesic. The baby's heart rate is unlikely to exhibit transient accelerations after the mother receives analgesics.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage

3.Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5.Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education Hypnotic suggestion is usually not included in childbirth education based on the Lamaze method. Rhythmic chanting is usually not included in childbirth education based on the Lamaze method. TEST-TAKING TIP: The test taker may have expected to find breathing techniques included in the question related to Lamaze childbirth education. Although breathing techniques are taught, there are a number of other techniques and principles that couples learn in Lamaze classes. The test taker should be familiar with all aspects of childbirth education.

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

4. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction. Holding the breath for 20 seconds during each contraction can stimulate the Valsalva maneuver, which can lead to a sudden drop in blood pressure and fainting. One cannot push and blow out at the same time. This will not facilitate the delivery of the baby. Pushing should be done only during contractions, not between contractions. TEST-TAKING TIP: It is essential that the test taker read each question and the possible answer options carefully. If the test taker were to read response 3 quickly, he or she might mistakenly choose it as the correct response. Because the woman is being encouraged to push between contractions, however, the answer is incorrect.

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning.

4. The baby's head is almost crowning Engagement is equal to 0 station. This fetus well past 0 station. A baby who is floating is in negative station. When the presenting part is at the ischial spines, the baby is engaged or at 0 station. TEST-TAKING TIP: A baby is crowning when the mother's perineal tissues are stretched around the fetal head at the same location where a crown would sit. The station at this time is past +5 station (or 5 cm past the ischial spines).

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4. The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds. The frequency and duration of this contraction pattern is every 2 minutes lasting 60 seconds. The frequency and duration of this contraction pattern is every 4 minutes lasting 120 seconds. The frequency and duration of this contraction pattern is every 3 minutes lasting 120 seconds. TEST-TAKING TIP: The test taker must recall that frequency is defined as the time from the beginning of one contraction to the beginning of the next, while duration is defined as the beginning of the increment of a contraction to the end of the decrement. The only choices that include a frequency of 3 minutes are choices 3 and 4. Of these, the only choice with a duration of 60 seconds is choice 4.

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

4.Most women find slow chest breathing effective during the latent phase. The pant-blow breathing technique is usually used during the transition phase of labor. Rapid, deep breathing is rarely used in labor. Grunting and pushing, characteristic of open glottal pushing, is the method that women instinctively use during the second stage of labor. It is also the safest method of pushing. TEST-TAKING TIP: Because the latent phase is the first phase of the first stage of labor, the contractions are usually mild and they rarely last longer than 30 seconds. A slow chest breathing technique, therefore, is effective and does not tire the woman out for the remainder of her labor. It is important to note that couples who have learned the Bradley method of childbirthing are encouraged to perform relaxed breathing throughout their labors.

A woman who is in active labor is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

4.When the baby's chin is on his or her chest, the baby is in the flexed attitude. A baby in the breech presentation may or may not be in the flexed attitude. A baby in the horizontal lie may or may not be in the flexed attitude. Engagement is unrelated to attitude. TEST-TAKING TIP: The diameter of the fetal head is dependent upon whether or not the head is flexed with the chin on the chest or extended with the chin elevated. When the baby is in the flexed attitude, with the chin on the chest, the diameter of the fetal head entering the pelvis averages 9.5 cm (the suboccipitobregmatic diameter), whereas if the baby is in the extended attitude, with the chin elevated, the diameter of the fetal head entering the pelvis can be as large as 13.5 cm (the occipitomental diameter). For the fetal head to pass through the mother's pelvis, therefore, it is best for the head to be in the flexed attitude

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

A fetus in the mentum anterior position is unlikely to elicit severe back pain in the mother. A fetus in the sacral posterior position is unlikely to elicit severe back pain in the mother. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain. A fetus in the scapula anterior position is unlikely to elicit severe back pain in the mother. TEST-TAKING TIP: If the test taker were to view a picture of a baby in the occiput posterior position, he or she would note that the occiput of the baby lies adjacent to the coccyx of the mother. During each contraction, the occiput, therefore, is forced backward into the coccyx. This action is very painful.

When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

The left upper quadrant would be the appropriate place to place a fetoscope to hear the fetal heartbeat if the baby were in the LSA position, not the LOA position. The right upper quadrant would be appropriate if the baby were in the RSA position. The right lower quadrant would be appropriate if the baby were in the ROA position. TEST-TAKING TIP: The fetal heart is best heard through the fetal back. Because, as determined by doing Leopold maneuvers, the baby is LOA, the fetal back (and, hence, the fetal heart) is in the left lower quadrant.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal examinations. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal examinations. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 5. The nurse should assess the fetal heart before the woman ambulates. The fetal heart pattern should be assessed every hour during the latent phase of a low-risk labor. It is not standard protocol to assess every 10 minutes. TEST-TAKING TIP: Except for invasive procedures, assessment of the fetal heart pattern is the only way to evaluate the well-being of a fetus during labor. The fetal heart pattern should, therefore, be assessed whenever there is a potential for injury to the baby or to the umbilical cord. At each of the times noted in the scenario—vaginal examination, analgesic administration, contraction, and ambulation—either the cord could be compressed or the baby could be compromised.

In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2. Effleurage is a light massage that can soothe the mother during labor. The lithotomy position is not physiologically supportive of labor and birth. Practicing Kegel exercises can help to build up the muscles of the perineum but will not help the woman to work with her labor. Pushing is not performed until the second stage of labor. TEST-TAKING TIP: There are a number of actions that mothers can take that can support their breathing during labor. Walking, swaying, and rocking can all help a woman during the process. Effleurage, the light massaging of the abdomen or thighs, is often soothing for laboring mothers.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Station is assessed by palpating the ischial spines. Palpating the sacral promontory assesses the obstetric conjugate, not the fetal station.Palpating the cervix assesses dilation and effacement, not fetal station. Palpating the symphysis pubis assesses the obstetric conjugate, not the fetal station. TEST-TAKING TIP: The test taker must be thoroughly familiar with the anatomy of the female reproductive system and the measurements taken during pregnancy and labor. Station is determined by creating an imaginary line between the ischial spines. The descent of the presenting part of the fetus is then compared with the level of that "line."

The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? 1. Spontaneous fetal movement. 2. Fetal heart acceleration. 3. Increase in fetal heart variability. 4. Resolution of late decelerations.

2. The fetal heart should accelerate in response to scalp stimulation. Fetal movement is noted during labor, but it is not directly related to the fetal scalp stimulation test. The variability does not change in direct response to the fetal scalp stimulation test. Late decelerations are related to uteroplacental insufficiency. The fetal scalp stimulation test will not affect a late deceleration pattern. TEST-TAKING TIP: The fetal scalp stimulation test is performed by the healthcare practitioner when the fetal heart pattern is equivocal. For example, if the variability is questionable, the practitioner may perform the stimulation test. If the fetal heart rate accelerates in response to the test, the nurse interprets the response as a positive sign.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2. The woman is showing expected signs of the active phase of labor. There is no indication that this woman has had poor preparation for childbirth. There is no indication that this woman is showing signs of hypoxia and/or hypercapnia. The alpha-fetoprotein assessment is a test to screen for Down syndrome and neural tube defects in the fetus. It is done during pregnancy. TEST-TAKING TIP: The test taker must be familiar with the different phases of the first stage of labor: latent, active, and transition. The multiparous woman in the scenario entered the labor suite in the latent phase of labor when being talkative and excited is normal, but after 1 hour she has progressed into the active phase of labor in which being serious and breathing rapidly with contractions are expected behaviors

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2. The woman should be encouraged to grunt during contractions. The fetal heart should be assessed every 5 minutes or less during the second stage of labor. The pulse should be assessed, but it is unnecessary to do so every 5 minutes. There is no one pushing position that is required. Women may push while squatting, on hand and knees, or in a number of other positions. TEST-TAKING TIP: During second stage labor, the woman should push on an open glottis to prevent the vasovagal response. Research has shown that when women push without being coached, they do not hold their breath to bear down, b

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. 2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Baseline of 140 to 142 with no obvious decelerations or accelerations.

2.A baseline FHR of 140 to 150 is a baseline showing moderate, or normal, variability. Decelerations that mirror contractions are defined as early decelerations. These are related to head compression and are expected during transition and second stage labor. A baseline fetal heart rate (FHR) of 140 to 150 is a baseline with moderate variability, but V-shaped decelerations are variable decelerations. These are related to cord compression and are not normal. A baseline with beat-to-beat changes of only 2 bpm is defined as minimal variability. Also, there are late decelerations. Late decelerations are related to uteroplacental insufficiency. This situation is an obstetric emergency. A baseline with beat-to-beat changes of only 2 bpm is defined as minimal variability. Even when no decelerations are noted, the nurse should be concerned when the FHR is showing minimal variability. TEST-TAKING TIP: The test taker must be prepared to differentiate between normal situations and obstetric emergencies. Even though there are decelerations in choice 2, they are early decelerations and they are expected because the woman is currently in the transition phase of the first stage of labor.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3. Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed in the LUQ. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed LLQ. The monitor electrode should have been placed in the RLQ if the nurse had assessed a vertex presentation. TEST-TAKING TIP: Although the question does not tell the test taker whether the sacrum is facing anteriorly or posteriorly, it does provide the information that the sacrum is felt toward the mother's right. Because this baby is in the sacral presentation and the back is toward the right, the best location for the fetal monitor is in the RUQ, at the level of the fetal back

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's healthcare practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Continue to provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

3. Because this is a normal finding, the nurse should continue to provide labor support and encouragement. Bloody show and perineal bulging are normal findings. There is no need to notify the health care practitioner at this time. Bloody show and perineal bulging are normal findings. The woman is not in need of immediate cardiovascular assessment. Bloody show and perineal bulging are normal findings.. There is no need to administer oxygen or to change the woman's position. TEST-TAKING TIP: The bulging perineum is an indication that the baby is descending in the birth canal and the bloody show results from injury to the capillaries in the mother's cervix. Because this woman is a primigravida, she will likely need to push for many more minutes so it is not necessary to notify the healthcare provider until additional signs are noted.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions hurt more than they did before." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."

3. This response indicates that the labor contractions are increasing in intensity. The frequency of labor contractions decreases. It does not increase. Labor contractions increase in intensity. They do not become milder. This client has slept through the "tightening" and there is no increase in intensity. It is unlikely that she is in true labor. TEST-TAKING TIP: The test taker should review the labor contraction definitions of frequency, duration, and intensity. As labor progresses, the frequency of contractions decreases but the duration and the intensity, or the length and strength, of the contractions increase. The nurse notes the change in intensity when he or she palpates the fundus of the uterus, and the client subjectively complains of increasing pain.

A laboring woman and two men enter the labor suite. One of the men states, "We and our surrogate are here for our baby's delivery. Where should we go?" Which of the following responses by the nurse would be appropriate? 1. Congratulate the surrogate on the gift she is giving the gay couple. 2. Remind the men that labor and delivery experience is very stressful. 3. Remind the men that the woman is the baby's mother. 4. Ask the laboring woman whom she would like to be with her during labor.

4. The nurse should ask the laboring woman whom she would like to be with her during labor. Although it is true that the surrogate will surrender her baby to the gay couple, that is not the appropriate response for the nurse to give. Although it is true that the labor and delivery experience is very stressful, that is not the appropriate response for the nurse to give. Because the woman is carrying the baby and will birth the baby, from a biological perspective, the woman is the baby's mother. That is, however, not the appropriate response for the nurse to give. TEST-TAKING TIP: The nurse may care for clients with a variety of lifestyle choices. It is imperative for the nurse to be mindful, however, that each client will have her own needs and desires. Even though a surrogate has promised to surrender her baby to an infertile couple—whether heterosexual or homosexual—it is she who will be going through labor and delivery. During that period, her needs for companionship or privacy should take priority

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the healthcare practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. This is the correct response. A fetal heart rate of 152 is normal. This woman is in early labor. The fetal heart does not need to be assessed every 5 minutes. The rate is normal. There is no need to report the rate to the healthcare practitioner. The rate is normal. There is no need to institute emergency measures. TEST-TAKING TIP: It is essential that the test taker know the normal physiological responses of women and their fetuses in labor. The normal fetal heart rate is 110 to 160 bpm. A rate of 152, therefore, is within normal limits. No further action is needed at this time.

A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

2. A wedge should be placed under one side of the woman. There is no indication that a blanket roll needs to be placed under the woman's feet at this time. It is not necessary for the nurse to assess the pedal pulses at this time. The temperature does not need to be assessed immediately after the epidural insertion TEST-TAKING TIP: Hypotension is the most common complication of epidural anesthesia in labor. One of the most important reasons for this is the compression of the vena cava by the pregnant uterus. When a wedge is placed under the woman's side—usually the right side—the uterus is tilted, relieving the pressure on the great vessels.

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

2. These are signs of placental delivery. Considering the signs, this is an unlikely reason. Considering the signs, this is an unlikely reason. Cord bloods are obtained by the practitioner once the cord is cut. The clamp on the cord that is still attached to the placenta is released and blood is obtained from the cut cord. TEST-TAKING TIP: Although they sound abnormal, the following are the normal signs of placental separation: The uterus rises in the abdomen and becomes globular, there is a gush of blood expelled from the vagina, and the umbilical cord lengthens. The placenta should be delivered between 5 and 30 minutes after the delivery of the baby.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. Although this client is light-headed, her problem is unlikely related to her blood pressure. It is unnecessary for this client to be moved to her side. The baby is not in jeopardy at this time. TEST-TAKING TIP: It is essential that the test taker attend to the clues in the question and not assume that other issues may be occurring. This client is light- headed as a result of being tachypneic during contractions. Hyperventilation, which can result from tachypnea, is characterized by tingling and light- headedness. Rebreathing her air should rectify the problem.

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

3. Because this woman is a multipara, the position is LOA, and the station is +3, Epidurals are a form of regional anesthesia. They are used to obliterate pain. It is inappropriate to encourage the woman to receive an epidural at this time. his is an accurate statement. It is inappropriate to encourage the woman to receive an epidural at this time. TEST-TAKING TIP: The average length of the second stage of labor for multiparas is about 15 minutes, whereas the average time for an epidural to be inserted and to take effect is approximately 20 minutes. In addition, the fetus in the scenario has already descended to +3 station and is in the optimal position for delivery—LOA. It is very likely that this baby will be born in a few contractions. The nurse should encourage the client to continue pushing with her contractions.

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. It is essential to assess the fetal heart rate immediately after an amniotomy. The maternal blood pressure is not the priority assessment after an amniotomy. the maternal pulse is not the priority assessment after an amniotomy. Fetal fibronectin is assessed during pregnancy. It is not assessed once a woman enters labor. TEST TAKING TIP: Amniotomy, as the word implies, is the artificial rupture of the amniotic sac. During the procedure, there is a risk that the umbilical cord may become compressed. Because there is no direct way to assess cord compression, the nurse must assess the fetal heart rate for any adverse changes.

While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical. With the palpation findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal position in not transverse. The findings on palpation also indicate that the presentation is not vertex.The attitude is difficult to determine when performing Leopold maneuvers. TEST-TAKING TIP: Many obstetric assessments have a component that is sensual and a component that is an interpretation or concept. Leopold maneuvers are good examples. The nurse palpates specific areas of the pregnant abdomen but then must interpret or translate what he or she is feeling into a concept. For example, in the scenario presented, the nurse palpates a hard round mass in the fundal area of the uterus and must interpret that feeling as the fetal head. Similarly, the nurse palpates a soft round mass above the symphysis and must interpret that feeling as the fetal buttocks. With these findings and interpretations, the nurse will then realize that the fetal lie is vertical.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. A vaginal examination will provide the nurse with the best information about the status of labor. Leopold maneuvers, although performed on a woman in labor, assess for fetal position, not the progress of labor. Fundal contractility will assess for uterine contractions, but this is not the most valuable information. Assessment of the fetal heart is critically important in relation to fetal well-being, but it will not determine the progress of labor. TEST-TAKING TIP: Each of the assessments listed is performed on a woman who enters the labor suite for assessment. However, the only assessment that will determine whether or not a woman is in true labor is a vaginal examination. Only when there is cervical change—dilation and/or effacement—is it determined that a woman is in true labor.

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil

4. Massaging of the perineum with mineral oil does help to reduce perineal tearing Squatting is an alternate position for delivery, but it is not used to decrease perineal tearing. Pushing the fetal head against the perineum is the cause of perineal tearing. Pushing the fetal head against the perineum is the cause of perineal tearing. TEST-TAKING TIP: During labor, nurses and nurse midwives often massage a woman's perineum to increase the elasticity of the tissue. Because the tissue is more elastic, it is less inclined to tear during the delivery. In addition, mothers are often encouraged to begin massaging the tissue during their last trimester.

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 g/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30.

4. This fetal pH value is within normal limits. Oxygen saturations are noninvasive assessments, whereas fetal scalp sampling assessments are performed on blood obtained from the fetal scalp. Fetal oxygen saturation levels are well below those seen in extrauterine life—approximately 50% to 75%. Normal fetal hemoglobin levels are well above those seen in extrauterine life—14 to 20 g/dL. This fetal glucose level is indicative of maternal hyperglycemia. This fetal pH value is within normal limits. TEST-TAKING TIP: It is essential that the test taker be aware that many fetal laboratory values are much different from those seen in extrauterine life. The nurse would expect to see fetal oxygen saturation of 50% to 75%, not 99%, and fetal hemoglobin levels of 14 to 20 g/dL, not 11 g/dL. The nurse would expect to see a fetal serum glucose level of 140 mg/ dL only if the mother had diabetes. The only expected value listed is a pH of 7.30 because this is consistent with a normal, slightly acidic fetal pH. The differences in fetal and extrauterine values reflect the fact that the fetus is not oxygenating efficiently through the lungs, as happens in the extrauterine environment, but rather is "breathing" indirectly via the placenta.

A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.

1, 5, 3, 4, 2. The correct order of the movements listed is: 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion. TEST-TAKING TIP: The test taker must review the cardinal moves of labor. There are a couple of tricks to help the test taker to remember the sequence of the moves of labor. First, descent and flexion must occur. If the baby does not descend into the birth canal and the baby does not flex the head so that his or her chin is on the chest, the baby simply will not be able to traverse through the bony pelvis. Second, internal rotation (rotation of the fetal body when the fetal head is still inside the mother's pelvis) must occur before external rotation (rotation of the fetal body after the fetal head is outside the mother). In between the rotational moves is extension, the delivery of the head. And, finally, expulsion must be last because the delivery of the baby's body is simply the last movement.

Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting, too." The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-relieving methods? 1. Epidural. 2. Nitrous oxide. 3. Narcotic analgesic. 4. Spinal

2. During labor, inhaled nitrous oxide exerts both a pain-relieving action as well as an anxiety-reducing action. Although epidural anesthesia will relieve the client's pain, it will not act to reduce the client's fears. Although a narcotic analgesic will reduce the client's pain, it will not act to reduce the client's fears. Although used frequently for delivery, spinal anesthesia is rarely used during labor for two important reasons: (1) It paralyzes the patient, resulting in her inability to move until the medication is fully metabolized and (2) once the medication is metabolized, if the client is still in pain, there is no way to readminister the medication. TEST TAKING TIP: When self-administered in a 50% N2O/50% O2 concentration, nitrous oxide has been shown to be an effective pain-relieving medication. As important, however, is its anxiolytic action. For women who exhibit anxiety or fear during labor, nitrous oxide is an excellent pain-relieving option

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Once the cervix begins to dilate, a client is in true labor. Women may contract without being in true labor. Membranes can rupture before true labor begins. Engagement can occur before true labor begins. TEST-TAKING TIP: Although laboring women experience contractions, contractions alone are not an indicator of true labor. Only when the cervix dilates is the client in true labor. False labor contractions are usually irregular and mild, but, in some situations, they can appear to be regular and can be quite uncomfortable.

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia. 4. Decreased respiratory rate.

2. The blood pressure rises dramatically. With pain and increased energy needs, the pulse rate often increases. Although the woman is working very hard, her temperature should remain normal. With pain and increased energy needs, the respiratory rate often increases. TEST-TAKING TIP: During contractions, the blood from the placenta is forced into the peripheral vascular system and there is an increase in cardiac output. As a result, the woman's blood pressure rises: an average of 35 mm Hg systolic and 25 mm Hg diastolic. The blood pressure should never be assessed during a contraction because the reading will be a marked distortion of the woman's true blood pressure.

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

2. The nurse is using reflection to acknowledge the client's concerns. The client may have a urinary tract infection with blood in the urine. First, however, the nurse should acknowledge the client's concerns. Although the woman's statement is consistent with the expulsion of the mucous plug, this response ignores the fact that the client is frightened by what she has seen. The nurse will want to clarify that the woman isn't actually bleeding, but the question should follow an acknowledgment of the woman's concerns TEST-TAKING TIP: Pregnant women are very protective of themselves and of the babies they are carrying. Any time a change that might portend a problem occurs, a pregnant woman is likely to become concerned and frightened. Certainly, seeing any kind of blood loss from the vagina can be scary. The nurse must acknowledge that fear before asking other questions or making other comments.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2.The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor. This client has probably moved into the second stage of labor. Providing a bedpan is not the first action. It is too early to notify the physician. It is too early to advise the mother to push. TEST-TAKING TIP: The average length of transition in multiparas is 10 minutes. This client is therefore likely to have moved into the second stage of labor. The nurse's first action, therefore, is to assess the progress of labor. If she is in second stage, the physician will be notified and the client will be encouraged to push. If she is not yet in second stage, she should continue breathing with her contractions.

The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care? 1. Encourage the father to hold his partner's hand during labor. 2. Ask the woman if she would like to speak with her priest. 3. Provide the woman with a long-sleeved hospital gown. 4. Place an order for the woman's postpartum vegetarian diet.

3. Observant Jewish women are expected to have their elbows covered at all times. A long-sleeved gown, therefore, should be provided for them An Orthodox Jewish man is forbidden by Jewish law from touching his mate whenever she is experiencing vaginal discharge. The religious leader of the Jewish people is the rabbi. A priest is the religious leader of Catholics and some other Christian sects. Observant Jewish women will follow a kosher diet that may or may not be vegetarian. TEST-TAKING TIP: There are a number of religious mandates that guide the lives of Jewish couples. The mandates surround everyday life—what to eat, what to wear, when work is allowed, and when it is prohibited—as well as life events such as sexuality and birthing. The nurse should have some familiarity with the many precepts of the Jewish religion to care for that population with cultural competence.

The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear-tension- pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle. Childbirth educators are not concerned with the possible verbalizations that laboring women might make. Breathing exercises can be quite tiring. Simply being in labor is tiring. The goal of childbirth education, however, is not related to minimizing the energy demands of labor. Although childbirth educators discuss maternal-newborn bonding, it is not a priority goal of childbirth education classes. EST-TAKING TIP: When a frightened woman enters the labor suite, she is likely to be very tense. It is known that pain is often worse when tensed muscles are stressed. Once the woman feels pain, she may become even more frightened and tense. This process becomes a vicious cycle. The information and skills learned at childbirth education classes are designed to break the cycle.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal examinations and blood tests. 2. Focusing the discussion on baby care rather than on labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

3. Using visual aids can help to foster learning in teens as well as adults. It is important to include all relevant information in the childbirth class. Baby care should be included, but it is also important to include information about labor and delivery. Having the classes conveniently located in the school setting often enhances teens' attendance. TEST-TAKING TIP: Because of their classroom experiences, adolescents are accustomed to learning in groups. The school setting is comfortable for them and, because of its location and its familiarity, is an ideal setting for childbirth education programs. In addition, educators often use visual aids to promote learning and because teens are frequent theatergoers, showing movies is an especially attractive way to convey information to them.

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4. A fetus in a scapular presentation is in a horizontal lie. A fetus in a sacral presentation is in a vertical lie. A fetus in an occipital presentation is in a vertical lie. A fetus in a mentum presentation is in a vertical lie. TEST-TAKING TIP: Lie is concerned with the relationship between the fetal spine and the maternal spine. When the spines are parallel, the lie is vertical (or longitudinal). When the spines are perpendicular, the lie is horizontal (or transverse). It is physiologically impossible for a baby in the horizontal lie to be delivered vaginally.

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

4. Moderate variability is indicative of fetal health. Moderate variability is indicative of fetal health, not of hypoxia. A change in variability indicates acidosis, not alkalosis. In this situation, there is no indication of acidosis. During sleep cycles, fetal heart rate variability decreases. TEST-TAKING TIP: It is important for the test taker to be familiar with situations that can change the fetal heart variability. Normal situations that can decrease the variability include fetal sleep, administration of central nervous system depressant medications, and prematurity. A normal situation that can increase the variability is fetal activity.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high.Although this client is fully dilated, the cervix is not fully effaced and the baby has not descended far enough. TEST-TAKING TIP: To answer this question, the test taker must methodically evaluate each of the given responses. Once the nurse determines that a woman is not yet fully dilated or effaced, it can be determined that the woman is still in stage 1 of labor. Choice 3 does show a woman who is fully dilated but who is yet to efface fully and whose baby is still above the vaginal introitus. Only choice 4 meets all criteria set forth in the question.

It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4. This is the best response Laboring clients are allowed to eat by some practitioners. Midwives are more likely to allow eating than physicians. This is a very negative statement that does not answer the client's question. It is unlikely that the woman will eat at established meal times. Plus, a regular diet is rarely given to laboring clients, even by midwives. TEST-TAKING TIP: Peristalsis slows dramatically during labor. Because of this, women rarely become hungry during labor, but they do need fluids and some nourishment. Clear fluids, including ice chips, water, tea, and bouillon, are often allowed. Ultimately, though, it is the healthcare practitioner's decision what and how much the client may consume.

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4.This client is exhibiting clear signs of true labor. Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen. This client may be in the latent phase of labor or may be experiencing false labor contractions. Either way, unless she is having other symptoms, there is no need to be seen by a healthcare practitioner. This client is having some bloody show with the expulsion of the mucous plug, but pink streaks are normal and can be seen hours to a few days before true labor begins. This client may be in the latent phase of labor, but there is no need to go to the hospital with "cramping." TEST-TAKING TIP: Nurses interpret the comments made by gravid women who are close to term. Clients, especially primiparas, are often anxious about the labor process and have difficulty interpreting what they are feeling. Only when the woman is experiencing contractions that are increasing in intensity and duration and decreasing in frequency, or when the woman has ruptured membranes, should she be encouraged to go to the hospital for an evaluation.