Labor/Birth Process
A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? Administer the medication piggybacked into a primary IV line using a pump. Give the medication as an intramuscular injection using the Z-track technique. Give the medication orally every hour for the first 4 hours. Assist with insertion of a central venous access device for administration.
A Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity.
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? Second Third First Fourth
B Stage three begins with the birth of the baby and ends with delivery of the placenta.
The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible? Vertex presentation Molding Caput succedaneum Cephalohematoma
B The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Effacement time and time when contractions are regular Time of mucus plug expulsion and full cervical dilation Complete cervical dilation (dilatation) and time of fetal birth Admission time and time of fetal birth
C The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which of the following is an advantage of adopting a kneeling position during labor? A. It helps the woman in labor to save energy. B. It facilitates vaginal examinations. C. It facilitates external belt adjustment. D. It helps to rotate the fetus in a posterior position.
D
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? 0 +4 +2 -2
D When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A fetus at 0 (zero) station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.
The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding? 0% effaced. 50% effaced. 75% effaced. 100% effaced.
B A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 0.5 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur? bloody show cervical ripening and softening lightening Braxton Hicks contractions
B The ripening and softening of the cervix that result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation (dilatation) of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucus plug is expelled as a result of cervical softening and increased pressure of the presenting part.
With which findings would the nurse anticipate a diagnosis of false labor? Regular contractions 8 minutes apart A feel of pressure in the pelvic region Cervical dilation of 1 cm Softening of the cervix
C To be in true labor, there needs to be cervical dilation and effacement. Cervical dilation of 1 cm does not show progression in dilation (dilatation) as the contractions are not effective in producing further dilation. The other options could possibly be signs of true labor with cervical dilation.
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long the client will be in labor? "Your partner is in active labor; they are progressing at this point and we will keep you posted." "Your partner is doing well and is in the second stage of labor; birth could be anytime now." "Your partner is in the active phase of labor, and birth will be within 2 to 3 hours, though it might be sooner." "Your partner is still in early latent phase of labor; it is too early to estimate when they will give birth."
A At 7 cm dilated, the client is considered in the active phase of labor. There is no science that can predict the length of labor. The client is progressing in labor, and it is best that the nurse not give the family a specific time frame.
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions get closer together with activity. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions cause "ripening" of the cervix.
A Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? Fetal lie Fetal position Fetal presentation Fetal attitude
A Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.
The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: frequency. peak. intensity. duration.
A Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.
The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? Reduce the rate of cesarean births among low-risk women. Ensure care during labor includes immunizations. Encourage women with previous cesareans to always have a cesarean. Ensure all couples receive preconception genetic counseling.
A Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? A. pain from the dilation (dilatation) or stretching of the cervix B. distention of the vagina and perineum C. hypoxia of the contracting uterine muscles D. pressure on the lower back, buttocks, and thighs
A In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.
When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories? A. change in estrogen-to-progesterone ratio B. decrease in number of oxytocin receptors C. decrease in the level of estrogen D. decrease in prostaglandins, leading to myometrium contractions
A One of the theories suggests that labor is initiated by a change in the estrogen-to-progesterone ratio. The number of oxytocin receptors have been noted to increase. Estrogen levels also increase, which in turn increases myometrial sensitivity to oxytocin. Prostaglandin levels also increase, which in turn leads to myometrial contractions.
A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? Women should be able to move about freely throughout labor. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. Routine intravenous fluid should be implemented. A woman should be allowed to assume a supine position.
A Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced 2) women should be able to move about freely throughout labor, not be confined to bed 3) women should receive continuous support from a caring other during labor 4) no interventions such as intravenous fluid should be used routinely 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of the frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? active phase perineal phase pelvic phase latent phase
A The client is likely in the active phase of labor, which is in the first stage, as evidenced by the increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the active phase is 6 to 10 cm. The latent phase is in the first stage of labor and characterized by positive coping, mild contractions, and cervical dilation (dilatation) of 1 to 6 cm. The pelvic and perineal phases are in the second stage of labor. Contractions are every 2 to 3 minutes and the client is fully dilated (10 cm).
The five "Ps" of labor are: passageway, passenger, position, powers, psych. passenger, posture, position, presentation, psych. passenger, position, presentation, pushing, psych. passenger, position, powers, presentation, psych.
A The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).
The nurse is monitoring a pregnant client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? second latent active third
A The second stage of labor is between full dilation (dilatation) and birth of the infant. This pregnant client has completed stage one (latent and active phases) and is in the second stage of labor. The third stage begins with the birth of the infant and ends with birth of the placenta. The latent phase begins at 0 cm dilation and ends when the cervix is dilated 6 cm. The active phase begins at 6 cm dilation and ends when the cervix is dilated 10 cm. Both the active and latent phases occur during the first stage of labor.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? The client reports back pain, and the cervix is effacing and dilating. The contraction pains are 2 minutes apart and 1 minute in duration. After walking for an hour, the contractions have not fully subsided. The contraction pains have been present for 5 hours, and the patterns are regular.
A True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? The fetus is in the true pelvis and engaged. The client is fully effaced. The fetus is floating high in the pelvis. The fetus has descended down the birth canal.
A When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.
When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis? Select all that apply. round-shaped inlet convergent side walls straight sacrum wide pubic arch dull ischial spines
A,D,E The features of a gynecoid pelvis are oval-shaped inlet, dull ischial spines, and wide pubic arch. The birth of a baby is easiest in a gynecoid pelvis. Straight sacrum and convergent side walls are seen in an android pelvis.
When going through the active phase of labor, clients often feel out of control. What intervention will help these clients best? intense nursing care positive reinforcement their significant other beside them just to be left alone
B Any client, even one who has taken natural childbirth classes, has a difficult time maintaining positive coping strategies during the active phase of labor. Many clients describe feeling out of control during this phase of labor. A client in the active phase needs support, encouragement, and positive reinforcement.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? A. lying on side, arms grasped on abdomen B. head elevated, grasping knees, breathing out C. squatting while holding her breath D. lying supine with legs in lithotomy stirrups
B For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? A.False pelvis B. Cervix C. Perineum D. Uterus
B The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? Emphasize that food and fluid should stop or be light. Ask the woman to describe why she believes that she is in labor. Tell the woman to stay home until her membranes rupture. Arrange for the woman to come to the hospital for labor evaluation.
B The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not she is in labor. The client may be in false labor, and more information should be obtained before she is brought to the hospital.
A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting? occiput buttocks chin acromion process
B The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. weight gain bloody show backache constipation lightening
B,C,E The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilation (dilatation). Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.
The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? Educate the client this fetal position may result in a longer labor. Prepare the client for cesarean birth of the fetus. Continue to monitor the progress of labor. Auscultate fetal heart rate (FHR) in the left upper quadrant.
C ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part. This is a common and favorable position for vaginal birth. Based on the ROA location, the nurse will auscultate FHR at the right lower quadrant of the client's abdomen (FHR will be loudest where the fetus' back is located). Occiput posterior (not anterior) positions are associated with longer, more difficult births.
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do? Do a vaginal exam to see if the placenta is stuck in the birth canal. Notify the primary care provider of the problem. Nothing. Normal time for stage three is 2 to 30 minutes. Increase the IV tocolytic to help in expulsion of the placenta.
C Following birth, the placenta is spontaneously expelled within 2 to 30 minutes, so there is no problem with this client. No further interventions are needed.
During the second stage of labor, a woman is generally: very aware of activities immediately around her. no longer in need of a support person. turning inward to concentrate on body sensations. anxious to have people around her.
C Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? extension expulsion engagement flexion
C The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client? Select all that apply. A. prescribed pain killers B. chewing gum C. massaging D. hand holding E. acupressure
C.D.E To provide comfort to the pregnant client, the nurse should make use of massage, hand holding, and acupressure to bring comfort to the pregnant client during labor. It is not advisable to provide chewing gum to a client in labor; it may cause accidental asphyxiation. Pain killers are not prescribed for a client experiencing labor.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? +1 -5 0 +4
D As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
During which time is the nurse correct to document the end of the third stage of labor? When the mother is moved to the postpartum unit Following fetal birth When pushing begins At the time of placental delivery
D The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? "This indicates that you start labor within the next 24 hours." "This is just a way of determining your progress in labor." "This means +1 and the baby is entering the true pelvis." "The presenting part is at the true pelvis and is engaged."
D 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? potential rapid birth of fetus increased risk of breech presentation potential placenta previa increased risk of infection
D After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? A. These contractions increase oxytocin sensitivity. B. These contractions make maternal breathing easier. C. These contractions increase the release of prostaglandins. D. These contractions help in softening and ripening the cervix.
D Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? engagement descent restitution crowning
D Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.
A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds? A. relaxin B. oxytocin C. prostaglandins D. catecholamines
D Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor.
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? A. stage three B. stage two C. active D. latent
D The client in labor undergoes numerous psychologic adaptations during labor. During the latent phase, the client is often talkative and happy, and yet anxious. During active phase, the client may show fear and anger. Both the latent and active phases occur during stage 1. During stages 2 and, the client may remain positive, but the work of labor is very intense.
A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are: relieved by walking. occurring in the abdomen and groin. lasting about 30 seconds. occurring about every 5 minutes.
D The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? LOP ROP LOA ROA
D The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Maternal heart rate and blood pressure Maternal request for pain medication The station in which the fetus is located Fetal heart rate in relation to contractions
D The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? cause discomfort over the top of uterus subside when walking around and use the lateral position remain irregular with the same intensity increase even if relaxing and taking a shower
D True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.
A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating: the fetus is sitting cross-legged above the cervix. one leg is presenting. one arm is presenting. the buttocks are presenting first with both legs extended up toward the face.
D n a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.
A pregnant client is being discharged from the labor and birth suite because of false labor. The client asks the nurse how to tell whether the contractions are true contractions or Braxton Hicks contractions. Which description(s) will the nurse mention as characteristic of true contractions? Select all that apply. A. begin and remain irregular B. often disappear with ambulation or sleep C. felt first abdominally and remain confined to the abdomen and groin D. increase in duration, frequency, and intensity E. begin irregularly but become regular and predictable F. felt first in lower back and sweep around to the abdomen in a wave
D,E,F True contractions begin irregularly but become regular and predictable; are felt first in the lower back and sweep around to the abdomen in a wave; continue no matter what the pregnant client's level of activity; increase in duration, frequency, and intensity; and achieve cervical dilatation. False (Braxton Hicks) contractions begin and remain irregular; are felt first abdominally and remain confined to the abdomen and groin; often disappear with ambulation or sleep; do not increase in duration, frequency, or intensity; and do not achieve cervical dilatation.
