CH 16 OB
The nurse is caring for a client who is in the third trimester of pregnancy. The client reports pain in the pelvic joints. What does the nurse recognize as the cause of the pain? There is relaxation of the pelvic joints.
371
The nurse is performing the pelvic examination of a client during the prenatal visit. Which pelvic type is heart shaped and least favorable for a vaginal birth? Android
374
Which of the following findings would be a cause for concern for a nurse who is monitoring an obstetrical client who is in early labor? Biparietal diameter of less than 9.25 cm Transverse lie Android pelvis
A biparietal diameter at term is typically noted at 9.25 cm and a finding that this measurement is less than that would cause concern related to the mode of delivery. A transverse lie would cause a concern relative to the mode of delivery, because a C section would be indicated. An android pelvis would cause a concern related to the mode of delivery. A vertex presenting part is a normal finding and would not cause concern. A general flexion attitude is a normal finding and would not cause concern. pp. 368, 371
Which pregnant client is likely to have a cesarean delivery? A client with the fetus in a transverse lie
A transverse lie indicates that the long axis of the fetus is at a right angle, diagonal to the long axis of the mother. As a result, a vaginal birth is not possible and the client will need a cesarean delivery. A cephalic presentation indicates that the fetal head will lead through the birth canal during labor. This presentation facilitates vaginal delivery. A fetal biparietal diameter of 9.25 cm indicates normal head growth, which can be easily delivered vaginally. If the presenting part is 4 cm below the spines, it indicates that birth is imminent. The part is not an indicator of the type of birth. p. 369
Which assessment finding in the client increases the risk for a forceps assisted birth? Android pelvis
An android pelvis has a narrow subpubic arch and the ischial spines have a narrow interspinous diameter. As a result, the client will have difficulty during a vaginal birth and may require a forceps-assisted delivery. Effacement of the cervix takes place at the onset of the labor and indicates that the client is in labor. A biparietal diameter of 9.25 cm indicates normal fetal head growth, which can be delivered vaginally. Involuntary UCs indicate that the client is in labor. p. 374
During a prenatal evaluation, the nurse notes that the client has a flat pelvis. What term does the nurse use to refer to this type of pelvis? Platypelloid
About 3% of women may have flat pelvis, which is referred to as platypelloid pelvis. It is flattened anteroposteriorly and wide transversely. About 50% of women have gynecoid pelvis or the classic female type of pelvis. It is slightly ovoid or transversely rounded. Android pelvis resembles the male pelvis and may be found in 23% of women. It is heart shaped or angulated. Anthropoid pelvis resembles the pelvis of anthropoid apes and may be found in 24% of women. It is oval and wider anteroposteriorly. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point. p. 371
Nurses can advise their clients that which of these signs precede labor? A return of urinary frequency as a result of increased bladder pressure Persistent low backache from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions Uterus sinks downward and forward in first-time pregnancies.
After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. p. 376
Which signs precede the onset of labor? A return of urinary frequency, because of increased bladder pressure Persistent low backache, from relaxed pelvic joints Stronger and more frequent uterine (Braxton Hicks) contractions Weight loss of 0.5 to 1.5 kg
After lightening, a return of the frequent need to urinate occurs, because the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Prior to the onset of labor it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed and weight loss of 0.5 to 1.5 kg will occur. A surge of energy is a phenomenon that is common in the days preceding labor. p. 378
What will the nurse mention about the effect of secondary powers during labor to the client? Contractions are expulsive in nature.
As soon as the presenting part of the fetus touches the pelvic floor, the client uses secondary powers or bearing-down efforts. This results in contractions that are expulsive in nature. The voluntary bearing-down efforts of the client also result in increased intraabdominal pressure. Primary powers signal beginning of labor with involuntary contractions that move downward over the uterus in waves. These contractions begin at pacemaker points in the thickened muscle layers of the upper uterine segment. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax. p. 375
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: Passenger. Passageway. Psychologic response. Powers. Position.
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 psychologic response. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation. p. 367
Which fetal attitude is seen in general flexion? The chin is flexed on the chest. The legs are flexed at the knees. The thighs are flexed on the abdomen. The arms are crossed over the thorax.
Attitude or posture refers to the relation of the fetal body parts to one another. The attitude of general flexion is seen in most pregnancies. The chin is flexed on the chest, as the back of the fetus is rounded. As a result, the legs are flexed at the knees, and the thighs are flexed on the abdomen. The arms are crossed over the thorax, and the umbilical cord lies between the arms and legs. An extended fetal head indicates a deviation from the normal attitude that may cause difficulties during childbirth. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it. p. 369
What are the common signs that are observed in the days preceding labor? Persistent low backache Blood-tinged cervical mucus Profuse vaginal mucus
Common signs that precede labor include persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Brownish or blood-tinged cervical mucus may be passed. The vaginal mucus becomes more profuse in response to the extreme congestion of the vaginal mucous membranes. In the days preceding labor women generally have a sudden surge of energy. They also experience a loss of 0.5 to 1.5 kg in weight. This is caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question. p. 376
A client complains of the urge to have a bowel movement during each contraction. What does the nurse inform the client ? This is a normal occurrence at the onset of labor."
Frequent bowel movements may be seen in some clients at the onset of labor because of the presence of stool in the rectum. Therefore, the nurse should instruct the client that it is a normal occurrence. Bowel movement during each contraction does not indicate an infection, so there is no need to evaluate the urine reports. The possibility of a complication during delivery can be confirmed only after evaluating the ultrasound reports of the client. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know. p. 380
The nurse knows that what occurs in the second stage of labor, the descent phase? The amniotic membranes rupture. The cervix cannot be felt during a vaginal examination. The woman experiences a strong urge to bear down. The presenting part is below the ischial spines.
During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter. p. 375
The sonographic reports of a pregnant client reveal extreme asynclitism of the fetal head. What does the nurse conclude from this report? Cephalopelvic disproportion will be seen during labor.
Extreme asynclitism of the fetal head makes the fetus unable to descend during the birth process and causes cephalopelvic disproportion. The fetal head is parallel to the anteroposterior plane of the pelvis in a synclitic position. The client will most probably have a cesearean delivery because extreme asynclitism indicates that the fetal head is deflected in a way that may interfere with vaginal delivery. Asynclitism, not extreme asynclitism, facilitates fetal descent, because the head is being positioned to accommodate the pelvic cavity. p. 378
The nurse assesses a fetus as being in the cephalic presentation. What does the nurse mean by the term "fetal presentation?" The part of the fetus that enters the pelvic inlet first
Fetal presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. In a cephalic presentation, the fetal head enters the pelvic inlet first. Fetal position is the relationship of the reference point on the presenting part of the fetus to the four quadrants of the mother's pelvis. The fetal lie is the relation of the long axis or spine of the fetus to the long axis or spine of the mother. The fetal attitude is the relation of the fetal body parts to one another in utero. p. 368
During the vaginal examination of a client, the nurse notes that the fetus is in an oblique lie. What does this indicate? The fetal lie will undergo change during labor.
If the fetus is in an oblique lie, it usually converts to a longitudinal or transverse lie during labor. In an oblique lie the long axis of the fetus lies at an angle to the long axis of the mother. Fetal lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Vaginal birth cannot occur when the fetus stays in a transverse lie. In the longitudinal lie, the long axis of the fetus is parallel with the long axis of the mother. Longitudinal lies are either cephalic or breech presentations, depending on the fetal structure that first enters the mother's pelvis. p. 369
A pregnant client who is nearing her due date informs the nurse that she would like a vaginal delivery. The nurse observes in the medical records that the presenting part is the sacrum. What does the nurse tell the client? "Vaginal delivery may not be possible."
If the presenting part of the fetus is the sacrum, it indicates a breech presentation. Vaginal delivery of a fetus in breech position carries increased risks and it is more likely that the client will have to have a caesarean delivery. It is inaccurate to inform the client that there will be no complications during the birth, because this is not something that the nurse can predict. A breech presentation does not indicate that the client needs to lose weight. Environmental and biologic factors are associated with congenital defects. p. 368
The nurse notes that the fetus in a laboring patient is in brow presentation. What is the expected occipitomental diameter? 13.5
In a brow presentation, the presenting part is the mentum or chin. The occipitomental diameter is 13.5 cm at term, which is too large to permit the infant's head to enter the pelvis region of the mother. The biparietal diameter, which is about 9.25 cm at term, is the largest transverse diameter. The smallest anteroposterior diameteris, the suboccipitobregmatic diameter, about 9.5 cm at term, is in a vertex presentation. In a sinciput presentation, the occipitofrontal diameter is about 12.0 cm at term, with moderate extension of the head. p. 370
The nurse is caring for a multiparous client. In which stage can the nurse expect the fetal head to be engaged in the pelvic inlet? After labor is established
In a multiparous client, the abdominal musculature is relaxed. The fetal head often remains freely movable above the pelvic brim, and becomes engaged in the pelvic inlet only after labor is established. In a nulliparous client, the uterus sinks downward and forward about 2 weeks before term, when the presenting part of the fetus descends into the true pelvis. The fetal head is engaged in the pelvic inlet before the onset of active labor. The abdominal muscles are firm in a nulliparous pregnancy and direct the presenting part into the pelvis. The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix. p. 377
The sonographic reports of a client indicate that the fetus has a cephalic presentation. What does the nurse tell the client? "Vaginal delivery will be the best choice."
In a well-flexed cephalic presentation, the biparietal diameter is the widest part of the head entering the pelvic inlet. When the head is in complete flexion, the fetal head is allowed to pass through the true pelvis easily. Therefore, a vaginal birth may have complications and the client may have a forceps or vacuum-assisted birth or cesarean birth. The fetal skull is flexible due to the open fontanels during birth. Fetal complications may be seen during labor if there is a forceps or vacuum-assisted birth, which may cause birth trauma. p. 368
Which statement is accurate with regard to normal labor? A single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent occurs. No complications are involved. Mechanisms of labor are involved.
In normal labor, a single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent is the trajectory that the nurse expects for a woman experiencing a normal labor. A normal labor usually has no complications and the movements of the mechanisms of labor are present. Although the amount of time varies with each woman, a normal uncomplicated labor is usually completed within 18 hours. STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it. pp. 376-377
Which nursing intervention is important when providing care for a pregnant client in the first stage of the labor? Encouraging the client to change position frequently
In the first stage of labor, the pregnant client may experience fatigue and discomfort. Therefore, the nurse instructs the client to change position frequently to relieve fatigue, increase comfort, and improve circulation. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Epidural anesthesia is administered only if the labor is prolonged and the client is unable to tolerate pain. The client may tighten the abdominal muscles or hold her breath in the second stage of labor. However, the nurse should advise the client against it to prevent fetal hypoxia. STUDY TIP: Develop a realistic plan of study. Do not set rigid, unrealistic goals. p. 375
Which are the factors that affect the onset of labor? Increasing intrauterine pressure Increasing estrogen levels Decreasing progesterone levels
Increasing intrauterine pressure, increasing estrogen levels, and decreasing progesterone levels affect the onset of labor. Increasing intrauterine pressure is associated with increasing myometrial irritability. This is caused by increasing concentrations of estrogen and decreasing progesterone levels. Oxytocin and prostaglandin levels are known to increase during the onset of labor. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude. pp. 376, 380
The nurse is teaching a client, who is pregnant for the first time, about the signals that indicate the beginning of labor. Which sign will the nurse mention as a signal for the beginning of labor? Involuntary contractions
Involuntary uterine contractions, or the primary powers, signal the beginning of labor. Pain in the pelvic joints does not signal the beginning of labor. It is a result of widening of the joint of the symphysis pubis and the resulting instability. The primary powers are responsible for the effacement and dilation of the cervix and the descent of the fetus. Effacement is the shortening and thinning of the cervix during the first stage of the labor. However, 100% effacement would indicate that the patient is well established in the labor process. Dilation of the cervix is the enlargement or widening of the cervical opening and cervical canal. This dilation progresses after the labor has begun. Full cervical dilation marks the end of the first stage of labor. p. 372
The nurse instructor is teaching a group of students about the structure of the fetal head during labor and birth. Which statement by the student indicates effective learning? "The fetal skull bones are united by membranous sutures."
Membranous sutures, including sagittal, lambdoidal, coronal, and frontal, unite the fetal skull bones. The fetal skull bones are flexible at birth and a slight overlapping of the bones may occur during labor. The two important fontanels are the anterior and posterior. The sutures and fontanels do not close at birth but instead allow flexibility to accommodate the brain, which continues to grow after birth. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety." p. 367
The nurse is providing care for a client with twins during labor. The nurse instructs the client to avoid lying flat on the back. Which condition does the nurse aim to prevent in the client during labor? Supine hypotension
Supine hypotension may be seen in the pregnant client when the ascending vena cava and descending aorta are compressed. The client is more at risk for hypotension in the case of multifetal pregnancy due to a drop in hydrostatic pressure when lying supine. Valsalva maneuver refers to the client holding her breath and tightening the abdominal muscles to help with pushing. Respiratory alkalosis may occur in a pregnant client due to hyperventilation and not by lying flat on the back. Epidural analgesia is often prescribed to decrease pain experienced during uterine contractions. p. 379
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 what? Bloody show.
Passage of the mucus 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. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints." p. 376
In order to accurately assess the health of the mother accurately during labor, the nurse should be aware of what? The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation
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 the second stage of labor because it may lead to a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know. p. 380
Which fetal presentations can be seen during birth? Breech Cephalic Shoulder
Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor. The breech presentation means that the buttocks, feet, or both the buttocks and feet together will appear first. The cephalic presentation means that the fetal head will be the first part to appear through the birth canal. The shoulder presentation means that the presenting part is the scapula. The terms oblique and transverse refer to the fetal lie, in which the long axis of the fetus is at a right angle diagonal to the long axis of the mother. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function. p. 368
The nurse should tell a primigravida that the definitive sign indicating that labor has begun is what? Progressive uterine contractions with cervical change.
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 mucus plug is a premonitory sign indicating that the onset of labor is getting closer Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 376
The nurse assisting a laboring client is aware that the birth of the fetus is imminent. What is the station of the presenting part? +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. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. p. 370
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Full cervical dilation marks the end of the first stage of labor
The active stage 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. 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. Full cervical dilation marks the end of the first stage of labor. No official "lull" phase exists in the first stage. Text Reference: pp. 374, 376
The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? It is diamond-shaped in appearance.
The anterior fontanel is diamond-shaped and measures about 3 cm by 2 cm. It closes by 18 months after birth. It lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel is triangular in shape and measures about 1 cm by 2 cm. It closes after 6 to 8 weeks of birth. It lies at the junction of the sutures of the two parietal bones and the occipital bone. p. 367
Which factors affect the process of labor and birth? Birth canal Contractions Fetus and placenta
The birth canal is made up of the mother's rigid bony pelvis and soft tissues. The shape and size of the pelvis helps to assess the labor progress. The soft tissues of the birth canal aid in the vaginal birth of the fetus. The frequency, duration, and intensity of the uterine contractions cause cervical dilation and expulsion of the infant from the uterus and vagina. The size of the fetal head, fetal presentation, fetal lie, fetal attitude, and fetal position determine how the fetus moves through the birth canal. The placenta also passes through the birth canal after the expulsion of the fetus. Endogenous endorphins produced by the body affect the perception of pain in the patient and not the birthing process. A decrease in blood glucose levels may occur during labor. However it is a normal endocrine change and does not affect the process of labor. Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer. p. 367
The nurse is caring for a client who had a normal vaginal birth. The client is concerned about the shape of the infant's head. What does the nurse tell the client? The bones of the skull continue to grow after birth. The shape of the head undergoes molding during labor. The sutures and fontanels make the skull flexible.
The bones of the skull continue to grow for some time after birth to accommodate the infant's brain. During labor, the shape of the head gets molded as the bones undergo a slight overlapping. The sutures and fontanels are membranous structures that unite the skull bones and make the skull flexible. Molding can be extensive, but the heads of most newborns assume their normal shape within 3 days after birth. The skull bones are held together by sutures and fontanels and are not firmly united in an infant. p. 367
The nurse is providing care for a client in the first stage of labor. The client's prenatal documentation indicates that the client has scarring on her cervix due to a past STI. What complication might the nurse predict in the client during labor? Slow cervical dilation
The cervical dilation is slowed if a previous vaginal infection has caused scarring of the cervix. This is because the dilation occurs by the drawing upward of the musculofibrous components of the cervix. Ferguson reflex refers to the maternal urge to bear down when the stretch receptors in the posterior vagina release endogenous oxytocin. The administration of epidural analgesia may slow the rate of fetal descent. Supine hypotension occurs due to a drop in hydrostatic pressure. p. 374
Which statement by the student nurse about the cervix indicates effective learning? "The cervix allows fetal descent into the vagina."
The cervix is a soft tissue that effaces (thins) and dilates (opens) to allow fetal descent into the vagina. The introitus is the external opening of the vagina. The pelvic floor muscles allow the fetus to rotate anteriorly and help it to pass through the birth canal. The lower uterine segment distends and accommodates the intrauterine contents when the wall of the upper segment thickens. 372
The nurse is assisting a client in labor. What neurologic changes does the nurse expect in the laboring client? Amnesia and sedation.
The client experiences amnesia between contractions in the second stage of labor. Endogenous endorphins produced by the body cause sedation. This also raises the pain threshold. Pressure of the presenting part causes physiologic anesthesia of the perineal tissues. This decreases the perception of pain. At the start of labor, the client may be euphoric. Euphoria first gives way to increased seriousness. Second, it gives way to amnesia between contractions. Finally, it leads to elation or fatigue after giving birth. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. p. 380
The nurse is assessing a client in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? Latent phase
The client is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase or active pushing phase occurs in the second stage of labor. In this phase, the client has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. p. 376
The nurse is providing care for a client in labor. What does the nurse instruct the client in the second stage of labor? "Avoid holding your breath or tightening the abdominal muscles."
The client may hold her breath and tighten the abdominal muscles for pushing during the second stage of labor. This activity is known as the Valsalva maneuver. The activity increases intrathoracic pressure, reducing venous return while increasing venous pressure. Therefore, the nurse instructs the client to avoid the Valsalva maneuver. The client should not point her toes, because it may cause leg cramps. The client should not avoid fluids if thirsty, because it may cause dehydration. The nurse should instruct the client to change positions every few minutes in order to facilitate delivery during the second stage of labor. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group. p. 379
When assessing a client for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? It is movable in the latter part of the pregnancy.
The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is the ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly. p. 371
A postpartum client is worried because her newborn's head has an abnormal shape instead of being round. The delivery documentation indicates that the newborn had molding upon delivery. What is nurse's best response? "The infant's head will assume a normal shape in 3 days."
The fetal skull bones are not completely fused and there may be a slight overlapping of the bones during the labor process. This causes molding of the fetal head. The molding is not permanent and the infant's head assumes a normal shape within 3 days of birth. Telling the client that the infant will look better after hair growth will not help alleviate the client's anxiety about the fetal head. The infant's head will assume a normal shape within 3 days, and the client need not wait for a month to massage the infant's head. Some infants may have an oddly shaped head, but in this case, the molding has occurred due to the labor. p. 367
Which pelvic shape is the most classic female pelvis shape and most conducive to vaginal labor and birth? Gynecoid
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. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. p. 371
The nurse is assessing a pregnant client who is due in 2 weeks. Which signs and symptoms preceding labor may the nurse expect to see in the client? . Loss of weight Pain in the groin Persistent low backache Blood-tinged cervical mucus
The pregnant client may have a weight loss of 0.5 to 1.5 kg in the days preceding labor, due to water loss from electrolyte shifts, caused by changes in estrogen and progesterone levels. Pain in the groin and persistent low backache may occur due to the relaxation of the pelvic joints. The extreme congestion of the vaginal mucous membranes may cause blood-tinged cervical mucus. A surge of energy is a common phenomenon in a pregnant client preceding labor. p. 376
The nurse assisting a laboring client recognizes the Ferguson reflex in the patient. What is the Ferguson reflex? Maternal urge to bear down
The maternal urge to bear down is known as the Ferguson reflex. The Ferguson reflex is occurs when stretch receptors in the posterior vagina cause 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. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal. p. 375
Which is an abnormal finding in a fetus during labor? The fetal heart rate is 190 beats/minute at term.
The normal range of fetal heart rate is 110 to 160 beats/minute at term. Therefore, 190 beats/minute is an abnormal finding in the fetus. The fetal head is usually in a synclitic position, which indicates that the head is parallel to the anteroposterior plane of the pelvis. The oxygen pressure decreases as the fetal lung fluid is cleared from the air passage during the birth process. This aids in immediate respiration after birth. The fetal circulation tends to decrease during labor because of uterine contractions. p. 379
Which fetal and maternal physiologic conditions does the nurse assess during the first stage of labor? Fetal heart rate Fetal circulation Maternal heart rate
The nurse assesses fetal heart rate to evaluate oxygen demands. Maternal position, uterine contractions, blood pressure, and umbilical cord blood flow may affect fetal circulation. There is a drop in the maternal heart rate during labor and the nurse should monitor it to be alert to any complications. The Valsalva maneuver may be seen in the patient during the second stage of labor. The client may hold her breath and tighten the abdominal muscles for pushing. Supine hypotension may be seen in the client during labor if the uterus is large or the client is obese or hypovolemic. p. 379
In which stage of labor does the nurse expect the placenta to be expelled? Third
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. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early. p. 377
During the vaginal examination of a client in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation does the nurse recognize? Shoulder
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. pp. 368-369
During a sterile vaginal exam, the nurse finds that the fetal position is ROA. What is the presenting part of the fetus? Occiput
The presenting part of the fetus is the part that appears first during the labor. The fetal position refers to the presenting part in relation to the mother's pelvis. The position is denoted by a three-part abbreviation. In this case, the letters ROA stand for right, occiput, and anterior. It means that the occiput is the presenting part and is located in the right anterior quandrant of the maternal pelvis. Sacrum will be denoted by the letter S. Scapula (shoulder) is denoted by Sc. Mentum (chin) is denoted by the letter M. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience. p. 370
With regard to primary and secondary powers, the maternity nurse should understand what? That primary powers are responsible for effacement and dilation of the cervix
The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in first-time mothers; they are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so. p. 372
What are the functions of the primary powers in the labor process? Dilation of the cervix Descent of the fetus Effacement of the cervix Expulsion of the infant from the uterus
The primary powers efface and dilate the cervix at the onset of labor. Dilation refers to the enlargement of the cervical opening. The diameter of the cervix increases from less than 1 cm to 10 cm. The primary powers increase UCs that help in the descent of the fetus. Effacement refers to the shortening and thinning of the cervix during the first stage of labor. The primary powers along with the secondary powers are used in the expulsion of the infant from the uterus. Endogenous endorphins that are naturally produced by the body raise the pain threshold in the patient. STUDY TIP: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation. pp. 372, 375
The nursing instructor asks a student about the different stages of labor. Which statement by the student indicates effective learning? "The second stage lasts from full dilation of the cervix to the birth of the fetus."
The second stage of labor is composed of two phases: the latent (passive fetal descent) phase and the active pushing phase. In the latent phase, the fetus continues to descend passively through the birth canal, rotating in an anterior position due to the uterine contractions. In the active pushing phase, the fetus presses on the stretch receptors of the pelvic floor. Abnormal bleeding may sometimes occur in the first stage of labor which needs prompt attention by the primary health care provider. The placenta separates in the third stage of the labor after the birth of the fetus. The full effacement and dilation of the cervix ends at the first stage of the labor. pp. 376-377
When is the best time to determine the station of the presenting part in a pregnant client? When the labor begins
The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Birth is imminent when the presenting part is at +4 cm to +5 cm below the spine. A week before the labor is too early to determine the station, because fetal descent has usually not begun. The delivery of the placenta occurs in the fourth stage of labor. Therefore, the birth process is already complete by this stage. The third stage involves the birth of the infant and ends with the expulsion of the placenta. Therefore, it is ineffective to determine the station at that point. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process. p. 370
Concerning the third stage of labor, what should nurses be aware of? The duration of the third stage may be as short as 3 to 5 minutes
The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. 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. STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms. p. 377
What are the different parts of the true pelvis? Brim Outlet Midpelvis
The true pelvis is involved in the birth process and is divided into three planes: the inlet, or brim; the midpelvis, or cavity; and the outlet. The brim or the pelvic inlet is the upper border of the true pelvis. It is made up of the upper margins of the pubic bone anteriorly and the iliopectineal lines along the innominate bones laterally. Posteriorly, it has the anterior upper margin of the sacrum and the sacral promontory. The pelvic outlet is the lower border of the true pelvis. It is ovoid and diamond shaped. It has the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly. The midpelvis, or the pelvic cavity, is a curved passage. It has a short anterior wall and a longer concave posterior wall. It has the posterior aspect of the symphysis pubis, the ischium, a portion of the ilium, the sacrum, and the coccyx. Android and anthropoid are the different basic types of the pelvis. STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts. p. 371
Fetal circulation can be affected by many factors during labor. Accurate assessment of the laboring woman and fetus requires knowledge of these expected adaptations. Which factor will affect fetal circulation during labor? Uterine contractions Blood pressure Umbilical cord blood flow
Uterine contractions during labor tend to decrease circulation and subsequent perfusion. Most healthy fetuses are well able to compensate for this stress and exposure to increased pressure while moving passively through the birth canal during labor. Maternal blood pressure is likely to have a significant effect on fetal circulation. Compression of the cord and reduction of umbilical blood flow affect fetal circulation. Maternal position may affect fetal circulation; however, fetal position is unlikely to disturb umbilical blood flow. The fetal sex does not affect umbilical blood flow. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience. p. 379
The nurse is briefing a client who is pregnant for the first time about "lightening." Which statement should the nurse mention to describe lightening to the client? Allows the client to breathe more easily.
When the fetal head descends into the true pelvis during "lightening," the client will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions. p. 376
During the vaginal examination of a laboring client, 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? 1 cm above the ischial spine.
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. p. 370
