Maternity Chapter 13 Labor and Birth Processes

The nurse should tell a primigravida that the definitive sign indicating that labor has begun is: A. progressive uterine contractions with cervical change. B. lightening. C. rupture of membranes. D. passage of the mucous plug (operculum).

A Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A. The fetal presenting part is 1 cm above the ischial spines. B. Effacement is 4 cm from completion. C. Dilation is 50% completed. D. The fetus has achieved passage through the ischial spines.

A Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

The nurse is caring for a pregnant client who is in the second stage of labor. The nurse instructs the client not to hold her breath or tighten the abdominal muscles while having intense labor pain. What is the rationale for this instruction? To prevent: A. The onset of fetal hypoxia. B. Maternal hypotension. C. increased fetal heart rate. D. Hemorrhoids in the client.

A While caring for a client who is in the second stage of the labor, the nurse should instruct the client to refrain from performing the Valsalva maneuver. During the Valsalva maneuver, the client holds her breath and tightens the abdominal muscles, which may reduce the oxygen content in the blood and cause fetal hypoxia. Tightening of the abdominal muscles increases the intrathoracic pressure and may cause hypertension in the client, but not hypotension. Due to reduced oxygen supply, the pulse rate may decrease and cause fetal bradycardia, but not tachycardia. The pressure exerted by the fetus on the vaginal wall during the delivery causes hemorrhoids, but these are not associated with the Valsalva maneuver.

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: Select all that apply. A. passenger. B. placenta. C. passageway. D. psychological response. E. powers. F. position.

A, C, D, E, F At least five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychological response.

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

A, C, E Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are, in turn, caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.

The lab reports of a patient in labor reveal 1+ proteinuria. Which physiologic mechanism is responsible for this lab finding? A. Increase in cervical dilation B. Breakdown of muscle tissue C. Increased white blood cell count D. Stagnation in the area of the vaginal introitus

B During normal labor, the patient's muscle tissues break down due to increased physical activity. Urine examination shows proteinuria of 1+, which is a normal finding in a patient who is in labor. Nausea and belching occur as a reflex response to full cervical dilation. An increase in white blood cell count does occur during labor; however, it is not related to normal proteinuria in labor. Great distensibility occurs in the area of the vaginal introitus during labor. Topics

What are the factors that enable the baby to initiate respiration immediately after birth? A. Fetal respiratory movements increase during labor. B. Fetal lung fluid is cleared from the air passage. C. Arterial carbon dioxide pressure is decreased. D. Arterial pH and bicarbonate level is increased

B Fetal lung fluid is cleared from the air passage as the infant passes through the birth canal during labor and vaginal birth. There is a decrease in fetal respiratory movements during labor. Arterial carbon dioxide pressure (Pco2) increases. There is a decrease in arterial pH and bicarbonate levels.

Nurses can help their patients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours C. Lull: no contractions; dilation stable; duration of 20 to 60 minutes D. Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

B The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

Concerning the third stage of labor, nurses should be aware that: A. the placenta eventually detaches itself from a flaccid uterus. B. the duration of the third stage may be as short as 3 to 5 minutes. C. it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. D. the major risk for women during the third stage is a rapid heart rate.

B The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

Which pelvic shape is most conducive to vaginal labor and birth? A. Android B. Gynecoid C. Platypelloid D. Anthropoid

B The gynecoid pelvis is round and cylinder shaped, with a wide pubic arch. Prognosis for vaginal birth is good. Only 23% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The platypelloid pelvis is flat, wide, short, and oval. The anthropoid pelvis is a long, narrow oval with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape.

The nurse is assessing a pregnant patient who is paralyzed due to a spinal injury at the level of the twelfth thoracic vertebra. Presently, she is in full-term gestation and under nursing care. What should the nurse inform the patient? A. "You may have a prolonged labor." B. "You may have painless uterine contractions." C. "Your uterus may not contract due to paralysis." D. "Your baby may develop neurologic problems."

B The pregnant patient is paralyzed due to a spinal lesion above the twelfth thoracic vertebra. In this case, the patient would not perceive the uterine contractions and thus would have painless uterine contractions. The spinal injury has no effect on the duration of labor. The uterine contractions are not dependent on any external forces, and thus this patient would have normal uterine contractions. Neurologic problems in the fetus are not a complication associated with spinal cord injury.

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

B When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

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

C The maternal urge to bear down is known as the Ferguson reflex. The Ferguson reflex occurs when stretch receptors in the posterior vagina cause the release of endogenous oxytocin. The involuntary uterine contractions or primary powers originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment. Intrauterine pressure caused by contractions exerts pressure on the descending fetus and the cervix. When the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs.

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

C The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

The nurse is assessing a client who is 6 months pregnant. The nurse determines that the fetus is lying in a longitudinal position with the sacrum as the presenting part and with general flexion. What fetal position should the nurse document? A. Cephalic presentation B. Shoulder presentation C. Complete breech position D. Single footling breech position

C While assessing a pregnant client, the nurse should check the fetal lie, fetal attitude, and the presenting part in order to determine the fetal position. If the fetus lies in the longitudinal or vertical position with sacrum and feet as the presenting part and with general flexion it indicates that the fetus is in complete breech position. If the presenting part is the head instead of sacrum, then the fetus is in the cephalic position. If the fetus lies in the longitudinal or vertical position with the sacrum as the presenting part but with only one leg extended at the hip and knee, the fetus is in single footling breech.

In order to assess the health of the mother accurately during labor, the nurse should be aware that: A. the woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. B. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. C. having the woman point her toes reduces leg cramps. D. the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.

D Physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of potentially unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

The nurse is monitoring the fetal heart rate (FHR) of a patient in week 20 of gestation. What FHR can the nurse expect at this stage? A. 100 beats/min B. 120 beats/min C. 140 beats/min D. 160 beats/min

D The FHR is higher earlier in the gestation. At 20 weeks' gestation, the FHR on an average is 160 beats/min approximately. The rate decreases progressively as the maturing fetus reaches term. An FHR of 100 beats/min is below the normal FHR. The normal range of FHR is 110 to 160 beats/min. An FHR of 120 beats/min at 20 weeks' gestation is not normal. The average FHR at term is 140 beats/min.

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

D The presenting part can be defined as that part of the fetus that lies closest to the internal os of the cervix. In the shoulder presentation, the presenting part is the scapula. In a cephalic presentation, the presenting part is usually the occiput. In a breech presentation, the presenting part is the sacrum. The sacrum is the presenting part in a frank breech presentation. The sacrum and feet are the presenting parts in a complete breech presentation.

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

Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm. When the lowermost portion of the presenting part is 1 cm above the spine, it is noted as minus (-)1. When the presenting part is 1 cm below the spine, the station is said to be plus (+)1. At +3, the presenting part is still descending the birth canal. Birth is imminent when the presenting part is at +4 to +5 cm.

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe: A. weight gain of 1 to 3 lbs. B. quickening. C. fatigue and lethargy. D. bloody show.

D Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.