Chapter 13: Labor and Birth Process
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:
1cm above the ischial spines
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?
Allowing the woman time to be alone.
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
Ask the woman to describe why she believes she is in labor
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?
Braxton Hicks contractions usually decrease in intensity with walking.
With which findings would the nurse anticipate a diagnosis of false labor?
Cervical dilation of 1 cm
Which cardinal movement of delivery is the nurse correct to document by station?
Descent
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?
Fetal heart rate in relation to contractions
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:
Lightening
A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
Lightening Bloody Show Backache
The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately?
Relaxation
A young couple are anxious for the birth of their child. This is the couple's first child. The nurse discusses the options, including elective induction of labor for nulliparas. The nurse determines that additional teaching is necessary when the couple identifies which condition as being associated with this procedure?
Shorter hospitalizations
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
The client's cervix is fully dilated
The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care?
a woman may spend time thinking about what is happening to her
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?
increase even if relaxing and taking a shower
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?
lie
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
The cervix is softening
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?
Transition phase
A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?
transverse (biparietal)
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?
"She is in active labor; she is progressing at this point and we will keep you posted."
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged."
