Chapter 13-
A nurse is assessing a woman in labor. Which finding would 0 the nurse identify as a cause for concern during a contraction? A Heart rate increase from 76 bpm to 90 bpm B Blood pressure rise from 110/60 mm Hg to 120/74 C White blood cell count of 12,000 cells/mm3 D Respiratory rate of 10 breaths /minute
D
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. Vertex presentation b. Molding c. Caput succedaneum d. Cephalohematoma
b. Molding
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? a. Third b. Fourth c. First d. Second
a. Third Explanation:Stage three begins with the birth of the baby and ends with delivery of the placenta
A woman in her third trimester comes to the clinic for a4 prenatal visit. During assessment the woman reports that her. breathing has become much easier in the last week but she has noticed increased pelvic pressure , cramping and lower back pain. The nurse determines that which of the following has most likely occurred? A Cervical dilation B Lightening C Bloody show D Braxton-Hicks contractions
B
Assessment of a fetus identifies the buttocks as the presenting 3 part, with the legs extended upward. The nurse identifies this . as which type of breech presentation? A Frank B Full C Complete D Footling
A
A nurse admits a patient to the Labor and Delivery unit who reports that their water bag broke. The nurse will ask for what other information about the BOW? Select all that apply: A. time the BOW broke B. amount of fluid C. color of the fluid D. temperature of the fluid E. odor of the fluid
A. time the BOW broke B. amount of fluid C. color of the fluid E. odor of the fluid
A client is admitted to the labor and birthing suite in early. labor. On review of her medical record, the nurse determines that the clients pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A Platypelloid B Gynecoid C Android D Anthropoid
B
A woman calls the health care facility stating that she is in. labor. The nurse would urge the client to come to the facility if the client reports which of the following? A. Increased energy level with alternating strong and weak ) contractions B. Moderately strong contractions every 4 minutes, lasting about 1 ) minute C. Contractions noted in the front of abdomen that stop when she ) walks D. Pink-tinged vaginal secretions and irregular contractions lasting ) about 30 seconds
B
A client has not received any medication during her labor. She . is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A. Latent phase of the first stage of labor ) B. Active phase of the first stage of labor ) C. Transition phase of the first stage of labor ) D. Pelvic phase of the second stage of labor
C
A nurse is documenting fetal lie of a woman in labor. Which 6 term would the nurse most likely use? A Flexion B Extension C Longitudinal D Cephalic
C
Assessment of a pregnant woman reveals that the presenting 6 part of the fetus is at the level of the maternal ischial spines. . The nurse documents this as which station? A. 2 B. 1 C. 0 D. +1
C. 0
A fetus is assessed at 2 cm above the ischial spines. The nurse 2 would document fetal station as: A +4 B +2 C. 0 D. 2
D
A nurse is caring for several women in labor. The nurse2 determines that which woman is in the transition phase of . labor? A Contractions every 5 minutes, cervical dilation 3 cm B Contractions every 3 minutes, cervical dilation 5 cm C Contractions every 2 minutes, cervical dilation 7 cm D Contractions every 1 minute, cervical dilation 9 cm
D.
A G1P0 patient had a rubella titer drawn during the first prenatal visit. The nurse explains that this test detects: A. Rh status B. blood type C. syphilis D. immunity to German measles
D. immunity to German measles
Which cardinal movement of delivery is the nurse correct to document by station? a. Descent b. Internal rotation c. Flexion d. Extension
a. Descent
During which time is the nurse correct to document the end of the third stage of labor? a. When the mother is moved to the postpartum unit b. When pushing begins c. Following fetal birth d. At the time of placental delivery
d. At the time of placental delivery
When assessing cervical effacement of a client in labor, the . nurse assesses which of the following characteristics? A. Extent of opening to its widest diameter B. Degree of thinning C. Passage of the mucous plug D. Fetal presenting part
B
A patient presents to the hospital in labor. The nurse performs a SVE that reveals: 4/30/-1. What does the data from the SVE indicate? A. second stage; latent phase; 4 cm effaced; 30% dilated; -1 station B. first stage; latent phase; 4 cm dilated; 30% effaced; -1 station C. second stage; active phase; 4 cm dilated; 30% effaced; -1 station D. first stage; active phase; 4 cm dilated; 30% effaced; -1 station
B. first stage; latent phase; 4 cm dilated; 30% effaced; -1 station
A women in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A. Im feeling contractions mostly in my back. B. My contractions are about 6 minutes apart and regular. ) C. The contractions slow down when I walk around. ) D. If I try to talk to my partner during a contraction, I cant.
C
A woman telephones her health care provider and reports that 0 her water just broke. Which suggestion by the nurse would be . most appropriate? a. Call us back when you start having contractions. B. Come to the clinic or emergency department for an evaluation. C Drink 3 to 4 glasses of water and lie down. D Come in as soon as you feel the urge to push.
B
A woman is in the first stage of labor. The nurse would . encourage her to assume which position to facilitate the progress of labor? A. Supine B. Lithotomy C. Upright D. Kneechest
C
The nurse is reviewing the medical record of a woman in labor 7 and notes that the fetal position is documented as LSA. The. nurse interprets this information as indicating which of the following is the presenting part? A Occiput B Face C Buttocks D Shoulder
C
After teaching a group of students about the maternal bony1 pelvis, which statement by the group indicates that the teaching . was successful? A The bony pelvis plays a lesser role during labor than soft ) tissue. B The pelvic outlet is associated with the true pelvis. ) C The false pelvis lies below the imaginary linea terminalis. ) D The false pelvis is the passageway through which the fetus ) travels.
B
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. Maternal request for pain medication b. Fetal heart rate in relation to contractions c. The station in which the fetus is located d. Maternal heart rate and blood pressure
b. Fetal HR in relation to contractions 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 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 two b. transition phase c. latent phase d. stage three
c. latent phase The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage two she may remain positive, but the work of labor is very intense.
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
A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the. fetus goes through as it travels through the passageway, which of the following would the nurse most likely include? (Select all that apply.) A Internal rotation B Abduction C Descent D Pronation E. Flexion
A,C,E
The nurse is preparing to teach a group of soon-to-be new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens? a. Oblique lie b. Shoulder c. Breech d. Transverse lie
b. shoulder
A nurse is preparing a presentation for a group of pregnant 3 women about the labor experience. Which of the following would the nurse most likely include when discussing measures to promote coping for a positive labor experience? (Select all that apply.) A Presence of a support partner B View of birth as a stressor C Low anxiety level D Fear of loss of control E Participation in a pregnancy exercise program
A. C. E.
A patient at 16 weeks GA presents to the clinic for her first prenatal visit. Her history reveals that she had 7-year-old twins born at 34 weeks GA, a 2-year old born at 39 weeks GA, and a spontaneous abortion one year ago at 6 weeks GA. Using the GTPAL method, how would the nurse document her obstetric history? A. G3 P2103 B. G3 P1223 C. G4 P1113 D. G4 P2131
C. G4 P1113
A patient in labor received an opioid for pain relief close to the time of birth. Immediately after delivery, the nurse will closely assess the newborn for which of the following? A. Heart murmur B. High-pitched cry C. Respiratory depression D. Hypoglycemia
C. Respiratory depression
The nurse is reviewing the monitoring strip of a woman in9 labor who is experiencing a contraction. The nurse notes the . time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which of the following? A Increment B Acme C Peak D Decrement
A
The fetus of a nulliparous woman is in a shoulder presentation. . The nurse would most likely prepare the client for which type of birth? A. Cesarean B. Vaginal C. Forceps-assisted D. Vacuum extraction
A
Which of the following would indicate to the nurse that the . placenta is separating? A. Uterus becomes globular B. Fetal head is at vaginal opening C. Umbilical cord shortens D. Mucous plug is expelled
A
During the second stage of labor, a woman is generally: a. turning inward to concentrate on body sensations. b. very aware of activities immediately around her. c. no longer in need of a support person. d. anxious to have people around her.
a. turning inward to concentrate on body sensations.
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 facilitates external belt adjustment. b. It helps the woman in labor to save energy. c. It helps to rotate the fetus in a posterior position. d. It facilitates vaginal examinations.
c. It helps to rotate the fetus in a posterior position.
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? a. 0 to 2 b. 5 to 7 c. 8 to 10 d. 3 to 4
c. 8 to 10 Explanation: The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
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. Ensure care during labor includes immunizations. c. Reduce the rate of cesarean births among low-risk women. e. Ensure all couples receive preconception genetic counseling.
c. Reduce the rate of cesarean births among low-risk women.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. The station in which the fetus is located b. Maternal request for pain medication c. Maternal heart rate and blood pressure d. Fetal heart rate in relation to contractions
d. Fetal heart rate in relation to contractions
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. Internal rotation, descent, extension, flexion, external rotation, expulsion b. Internal rotation, flexion, descent, extension, external rotation, expulsion c. descent, flexion, external rotation, extension, internal rotation, expulsion d. descent, flexion, internal rotation, extension, external rotation, expulsion
d. descent, flexion, internal rotation, extension, external rotation, expulsion
Assessment of a woman in labor reveals cervical dilation of 3 . cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A Latent phase of the first stage B Active phase of the first stage C Transition phase of the first stage D Perineal phase of the second stage
A
After teaching a group of students about the factors affecting 5 the labor process, the instructor determines that the teaching . was successful when the group identifies which of the following as a component of the true pelvis? (Select all that apply.) A Pelvic inlet B Cervix C Mid pelvis D Pelvic outlet E Vagina F Pelvic floor muscles
A, C, D
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? a. reduction in length of the cervical canal b. shortening of the upper uterine segment c. restoration of blood flow to uterus and placenta d. effacement and dilation (dilatation) of the cervix
c. restoration of blood flow to uterus and placenta The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation of the cervix are other processes that occur during uterine contractions.
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. progesterone b. relaxin c. oxytocin d. prolactin
b. relaxin
When describing the stages of labor to a pregnant woman,1 which of the following would the nurse identify as the major change occurring during the first stage? A Regular contractions B Cervical dilation C Fetal movement through the birth canal D Placental separation
B
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 the release of prostaglandins. b. These contractions help in softening and ripening the cervix. c. These contractions make maternal breathing easier. d. These contractions increase oxytocin sensitivity.
b. These contractions help in softening and ripening the cervix.
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. brow c. shoulders d. occiput
d. Occiput Explanation: With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.
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. "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." b. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." c. "That is something we expect with a second or third baby, but because it is your first, you need to be checked." d. "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." Explanation: The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention. 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 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? a. lightening b. Braxton Hicks contractions c. cervical ripening and softening d. bloody show
a. Lightening
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? a. Radiates from the back to the front b. Occurs in an irregular pattern c. Slows when the woman changes position d. Lasts about 20 to 25 seconds
a. Radiates from the back to the front
A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess? a. fetal anomalies b. uterine abnormalities c. congenital anomalies d. birth after due date
a. fetal anomalies
During a follow-up prenatal visit, a pregnant woman asks the 4 nurse, How long do you think I will be in labor? Which. response by the nurse would be most appropriate? A. Its difficult to predict how your labor will progress, but we'll be there for you the entire time. B Since this is your first pregnancy, you can estimate it will be ) about 10 hours. C It will depend on how big the baby is when you go into labor. ) D Time isnt important; your health and the babys health are key.
A.
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. LOP b. ROP c. LOA d. ROA
d. ROA Explanation: 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.