OB PrepU Chapter 13

Which is the most important nursing assessment of the mother during the fourth stage of labor? a. Hemorrhage b. Heart rate c. Blood pressure d. The mother's psyche

a. Hemorrhage

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. a. dull ischial spines b. straight sacrum c. wide pubic arch d. convergent side walls e. round-shaped inlet

a. dull ischial spines c. wide pubic arch e. round-shaped inlet

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? a. 0 b. +2 c. +4 d. -2

d. -2

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: a. duration. b. intensity. c. peak. d. frequency.

d. frequency.

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: a. relieved by walking. b. occurring about every 5 minutes. c. occurring in the abdomen and groin. d. lasting about 30 seconds.

b. occurring about every 5 minutes.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? a. buttocks b. shoulders c. brow d. occiput

d. occiput

During which time is the nurse correct to document the end of the third stage of labor? a. At the time of placental delivery b. Following fetal birth d. When the mother is moved to the postpartum unit d. When pushing begins

a. At the time of placental delivery

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? a. presentation b. position c. lie d. attitude

c. lie

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most? a. just to be left alone b. their significant other beside them c. intense nursing care d. positive reinforcement

d. positive reinforcement

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? a. expulsion b. engagement c. extension d. flexion

b. engagement

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 to occur? a. Cervical ripening and softening b. Braxton Hicks contractions c. Lightening d. Bloody show

a. Cervical ripening and softening

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? a. +1 b. 0 c. +4 d. -5

c. +4

When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanel (fontanelle). Which description would the nurse include? a. approximately 2 to 3 cm in size b. located at the back of the fetal head c. triangular shape d. closes 8 to 12 weeks after birth

a. approximately 2 to 3 cm in size

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? a. prolactin b. progesterone c. relaxin d. oxytocin

c. relaxin

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? a. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. b. A woman should be allowed to assume a supine position. c. Routine intravenous fluid should be implemented. d. Women should be able to move about freely throughout labor.

d. Women should be able to move about freely throughout labor.

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? a. Has weaker bones than normal b. Is narrow transversely c. Is "male" shaped d. Is ideal for birth

b. Is narrow transversely

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? a. ROA b. ROP c. LOP d. LOA

a. ROA

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: a. descent, flexion, internal rotation, extension, external rotation, expulsion b. descent, flexion, external rotation, extension, internal rotation, expulsion c. internal rotation, flexion, descent, extension, external rotation, expulsion d. internal rotation, descent, extension, flexion, external rotation, expulsion

a. descent, flexion, internal rotation, extension, external rotation, expulsion

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? a. "I feel the tightening primarily in the front of my belly." b. "The contractions lessen after I drink a large glass of water." c. "I will have a strong one and then the next one will be weaker." d. "I feel pressure in my vagina when I have the contraction."

d. "I feel pressure in my vagina when I have the contraction."

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. Fetal heart rate in relation to contractions b. Maternal heart rate and blood pressure c. The station in which the fetus is located d. Maternal request for pain medication

a. Fetal heart rate in relation to contractions

A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? a. "This is not normal unless you are in active labor; come to the hospital and be checked." b. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." c. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital." d. "That is something we expect with a second or third baby, but because it is your first, you need to be checked."

b. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

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? a. Caput succedaneum b. Molding c. Cephalohematoma d. Vertex presentation

b. Molding

A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply. a. fresh gushing of blood from the vagina b. a relaxed and distended uterus c. falling downward of uterus in the abdomen d. umbilical cord descending lower down e. a globular shaped uterus

a. fresh gushing of blood from the vagina d. umbilical cord descending lower down e. a globular shaped uterus

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? a. Braxton Hicks contractions usually decrease in intensity with walking. b. Braxton Hicks contractions cause "ripening" of the cervix. c. Braxton Hicks contractions get closer together with activity. d. Braxton Hicks contractions do not last long enough to be true labor.

a. Braxton Hicks contractions usually decrease in intensity with walking.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document? a. completion of the third stage of labor b. transition phase c. attachment phase d. completion of the fourth stage of labor

a. completion of the third stage of labor

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? a. effacement b. dilation (dilatation) c. molding d. crowning

a. effacement

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. a. increase in blood pressure b. increase in respiratory rate c. increase in heart rate d. slight decrease in body temperature e. increase in gastric emptying and pH

a. increase in blood pressure b. increase in respiratory rate c. increase in heart rate

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? a. shoulder b. breech c. vertex d. cephalic

a. shoulder

A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? Select all that apply. a. strong desire to push b. apprehension mixed with excitement c. cervical dilation (dilatation) of 6 cm d. cervical effacement of 70% e. irritability with restlessness

a. strong desire to push e. irritability with restlessness

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? a. A caput succedaneum b. A cephalohematoma c. Wrapping of the head d. Developmental delay

b. A cephalohematoma

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? a. Encourage women with previous cesareans to always have a cesarean. b. Reduce the rate of cesarean births among low-risk women c. Ensure all couples receive preconceptional genetic counseling. d. Ensure care during labor includes immunizations.

b. Reduce the rate of cesarean births among low-risk women

A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: a. extreme pressure in the vaginal vault. b. cranial bones overlapping at the suture lines. c. prolonged labor. d. a congenital defect.

b. cranial bones overlapping at the suture lines.

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? a. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." b. "She is still in early latent labor and has much too long to go to tell when she will give birth." c. "She is in active labor; she is progressing at this point and we will keep you posted." d. "She is doing well and is in the second stage; it could be anytime now."

c. "She is in active labor; she is progressing at this point and we will keep you posted."

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client? a. Contractions are stronger during the first pregnancy than the second. b. Braxton Hicks contractions are not strong enough during first pregnancy. c. The cervix takes around 12 to 16 hours to dilate during first pregnancy. d. Spontaneous rupture of membranes occurs during first pregnancy.

c. The cervix takes around 12 to 16 hours to dilate during first pregnancy.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? a. The infant is born. b. The client experiences her first full contraction. c. The client's cervix is fully dilated. d. The client has contractions once every two minutes.

c. The client's cervix is fully dilated.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? a. start of regular contractions b. rupturing of fetal membranes c. dilation of cervix diameter to 10 cm d. diffuse abdominal cramping

c. dilation of cervix diameter to 10 cm

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? a. intensity b. frequency c. duration d. peak

c. duration

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. hypoxia of the contracting uterine muscles b. pressure on the lower back, buttocks, and thighs c. pain from the dilation or stretching of the cervix d. distention of the vagina and perineum

c. pain from the dilation or stretching of the cervix

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? a. "This is just a way of determining your progress in labor." b. "This indicates that you start labor within the next 24 hours." c. "This means +1 and the baby is entering the true pelvis." d. "The presenting part is at the true pelvis and is engaged."

d. "The presenting part is at the true pelvis and is engaged."

A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours? a. Don't mention anything to the client yet; wait for further dilatation to occur. b. "There has been no further dilation; effacement is progressing." c. "You haven't dilated any further, but hang in there; it will happen eventually." d. "You are still 2 cm dilated, but the cervix is thinning out nicely."

d. "You are still 2 cm dilated, but the cervix is thinning out nicely."

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? a. Give the medication orally every hour for the first 4 hours. b. Give the medication as an intramuscular injection using the Z-track technique. c. Assist with insertion of a central venous access device for administration. d. Administer the medication piggybacked into a primary IV line using a pump.

d. Administer the medication piggybacked into a primary IV line using a pump.

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. squatting while holding her breath c. lying supine with legs in lithotomy stirrups d. head elevated, grasping knees, breathing out

d. head elevated, grasping knees, breathing out

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? a. subside when walking around and use the lateral position b. remain irregular with the same intensity c. cause discomfort over the top of uterus d. increase even if relaxing and taking a shower

d. increase even if relaxing and taking a shower

Which client outcome during active and transitional labor is best? a. The client will practice breathing techniques during contractions. b. The client will state a pain level of 7 and under during contractions. c. The client will tolerate 8 oz (240 ml) of clear liquids during labor process. d. The client will walk in the hall for 15 minutes every 2 hours.

a. The client will practice breathing techniques during contractions.