Chapter 13: Labor and Birth Processes NCLEX

B (Rationale: Document the fetal position in the clinical record using abbreviations (Box 8-1). 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 or abbreviation 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.)

A 32-year-old woman presents to the labor-and-delivery 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) LOA b) ROA c) LOP d) ROP

D (ROA Rationale: Document the fetal position in the clinical record using abbreviations (Box 8-1). 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 or abbreviation 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.)

A 32-year-old woman presents to the labor-and-delivery 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) ROP b) LOP c) LOA d) ROA

D (Part of the fetal body entering the maternal pelvis first Rationale: The term presentation is the part of the fetal body that is entering the maternal pelvis first. Relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. Relation of the fetal presenting part to maternal ischial spine is termed the station.)

A client in labor has been admitted to the labor and birth suite. The nurse assessing her notes that the fetus is in a cephalic presentation. Which of the following should the nurse identify by the term presentation? a) Relation of the different fetal body parts to one another b) Relationship of the presenting part to the maternal pelvis c) Relation of the fetal presenting part to the maternal ischial spine d) Part of the fetal body entering the maternal pelvis first

A (Catecholamines Rationale: Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin and relaxin are not produced due to fear or anxiety in clients during labor.)

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which of the following is the nurse referring to in the explanation? a) Catecholamines b) Relaxin c) Prostaglandins d) Oxytocin

C (-2 Rationale: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.)

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

A (Buttocks Rationale: The letter "S" indicates the sacrum or buttocks as the presenting part. The fetal head would be noted by the letter "O," indicating occiput. The fetal chin would be noted by the letter "M," indicating mentum. The fetal shoulder would be noted by the letter "A," indicating the acromion process.)

A fetus is in the LST position. The nurse interprets this as indicating which of the following as the presenting part? a) Buttocks b) Fetal head c) Shoulder d) Chin

D (Gynecoid and platypelloid, respectively Rationale: The gynecoid is the typical female pelvis shape; platypelloid pelvis is the least common type of pelvis in women. Women with anthropoid pelvic shapes are able to deliver normally one third of the time, and are somewhat rare. An android pelvis is similar to a male pelvis, and is seen in 16% of nonwhite women.)

A new OB/GYN physician has just finished evaluating her one hundredth patient. In reviewing the documentation from all patients thus far, which types of pelvis would you assume the physician has seen the most and the least? a) Android and platypelloid, respectively b) Gynecoid and android, respectively c) Anthropoid and gynecoid, respectively d) Gynecoid and platypelloid, respectively

18

A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurse's answer is based on the knowledge that the anterior fontanel closes after birth by _____ months.

D (The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.)

A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurse's answer is based on the knowledge that the anterior fontanel closes after birth by _____ months. a. 2 b. 12 c. 8 d. 18

A (Women should be able to move about freely throughout labor Rationale: Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breast-feeding.)

A nurse is assisting a client who is in the first stage of labor. Which of the following principles should the nurse keep in mind to help make this client's labor and birth as natural as possible? a) Women should be able to move about freely throughout labor b) The support person's access to the client should be limited to prevent the client from becoming overwhelmed c) Routine intravenous fluid should be implemented d) A woman should be allowed to assume a supine position

A, B, D (Rationale: The normal physiologic changes for which a nurse should assess during the fourth stage of labor are a well-contracted uterus in the midline of the abdomen, mild cramping pain and generalized shivering, and decreased intra-abdominal pressure. Hemodynamic changes are due to normal blood loss during delivery, causing moderate tachycardia and a slight fall in the blood pressure during the fourth stage of labor. A fall in the pulse rate and increased blood pressure are not normal findings occurring during the fourth stage of labor.)

A nurse is caring for a client in her fourth stage of labor. Which of the following assessments would indicate normal physiologic changes occurring during the fourth stage of labor? Select all that apply. a) Well-contracted uterus in the midline b) Mild uterine cramping and shivering c) Increase in the blood pressure d) Decreased intra-abdominal pressure e) Decrease in the pulse rate

B (Say, "you are still 2 cm dilated, but the cervix is thinning out nicely." Rationale: Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, remember most women are aware of the word dilatation but not effacement. Just saying, "no further dilatation", therefore, is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening and that's just as important" is the same report given in a positive manner.)

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which of the following should the nurse do to best encourage the client regarding her progress? a) Don't mention anything to the client yet; wait for further dilatation to occur. b) Say, "you are still 2 cm dilated, but the cervix is thinning out nicely." c) Say, "you haven't dilated any further, but hang in there; it will happen eventually." d) Say, "there has been no further dilatation; effacement is progressing."

A (Suppresses the uterine irritability throughout pregnancy Rationale: The function of progesterone is to suppress uterine irritability throughout pregnancy. The function of estrogen is to promote oxytocin production and to sensitize the uterus to the effects of oxytocin. Prostaglandin, and not progesterone, stimulates the smooth muscle contractions in the uterus.)

A nurse is teaching a group of nursing students about the role of progesterone in labor. Which of the following should the nurse explain as the function of progesterone? a) Suppresses the uterine irritability throughout pregnancy b) Promotes oxytocin production from the posterior pituitary c) Sensitizes the uterus to effects of oxytocin on the myometrium d) Stimulates smooth muscle contraction in the uterus

A (Cannot be determined Rationale: Pelvis shape cannot be determined by the information included in the statement. Early in the pregnancy, particularly if a woman has never delivered a baby vaginally, the practitioner may take pelvic measurements to estimate the size of the true pelvis. This helps to determine if the size is adequate for vaginal delivery. However, these measurements do not consistently predict which women will have difficulty delivering vaginally, so most practitioners allow the woman to labor and attempt a vaginal birth.)

A petite, 5-foot tall, 95-pound woman who is 28 years old is about to deliver her first child and would like to have a vaginal delivery. She has two sisters, both of whom have given birth vaginally. She has gained 25 pounds during a normal, uneventful pregnancy. What type of pelvis would a nurse expect this woman to have upon assessment of the patient? a) Cannot be determined b) Android c) Platypelloid d) Gynecoid

C (This is a normal variation due to stress of labor Rationale: An elevation of WBC up to 30,000mm/3 can be normal variation for any woman after delivery. This is related to the stress on her body from labor and delivery. Antibiotics are not indicated as this is a normal response to intense stress. The increase in WBC is not related to cesarean birth. Retesting would be wasteful as it is known that this is a normal response to any stress.)

A post delivery CBC has noted an elevated WBC count of 22,000/mm3. Which rationale is accurate regarding the elevated WBC count? a) Abnormal finding and she needs antibiotics b) Might be a false result, recommend re-testing c) This is a normal variation due to stress of labor d) Occurs in patients who have cesarean birth, from the trauma of surgery

D (8-10 Rationale: The reaction of the patient is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8-10 cm. Before that, when dilation is 0-7 cm, the patient has an easier time using positive coping skills.)

A pregnant woman, multipara, has been in labor for several hours. She cries out that her contractions are getting harder and that she can't do this. The patient is really irritable, nauseated, annoyed, and fearful of being left alone. Considering the client's behavior, the nurse would expect the cervix to be dilated how many centimeters? a) 5-6 b) 0-2 c) 3-5 d) 8-10

D (This situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. These are all indications of false labor without fetal distress. There is no indication that further assessment or cesarean birth is indicated. The patient will likely be discharged; however, there is no indication that a sedative is needed.)

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. Admitted and prepared for a cesarean birth. b. Admitted for extended observation. c. Discharged home with a sedative. d. Discharged home to await the onset of true labor.

C ("She is in active labor, she is progressing at this point and we will keep you posted." Rationale: At 7cm dilated, she is considered in Active Phase of labor. There is no science that can predict the length of labor. She is progressing in labor and it is not best to give the family a specific time frame.)

A woman is documented on the labor and delivery board to be 7cm dilated. Her family wants to know how long she will be in labor. The nurse should provide which information to the family? a) "She is doing well, in the second stage and it could be anytime now." b) "She is in the transition phase of labor and it will be with in 2 to 3 hours, might be sooner." c) "She is in active labor, she is progressing at this point and we will keep you posted." d) "She is still in early latent labor and has much too long to go to tell when she will deliver."

B (It is completed within 8 hours)

All statements about normal labor are true except: a) A single fetus presents by vertex b) It is completed within 8 hours c) A regular progression of contractions, effacement, dilation, and descent occurs d) No complications are involved

B (The station of the presenting part should be noted at the beginning of labor so that the rate of descent can be determined. Position is the relation of the presenting part of the fetus to the four quadrants of the mother's pelvis; station is the measure of degree of descent. The largest diameter usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparas and before or during labor in multiparas.)

As relates to fetal positioning during labor, nurses should be aware that: a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b. Birth is imminent when the presenting part is at +4 to +5 cm below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d. Engagement is the term used to describe the beginning of labor.

B (50% effaced Rationale: A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 1/2 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.)

Assessment reveals that a woman's cervix is approximately 1 cm in length. The nurse would document this as: a) 100% effaced b) 50% effaced c) 0% effaced d) 75% effaced

D (Occiput Rationale: 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.)

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that the presenting part is which of the following? a) Brow b) Buttocks c) Shoulders d) Occiput

C (Braxton Hicks contractions usually decrease in intensity with walking Rationale: Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.)

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

B (The duration of the third stage may be as short as 3 to 5 minutes)

Concerning the third stage of labor, nurses should be aware that: a) The placenta eventually detaches itself from a flaccid uterus b) The duration of the third stage may be as short as 3 to 5 minutes c) It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface d) The major risk for women during the third stage is a rapid heart rate

D (Turning inward to concentrate on body sensations. Rationale: Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.)

During the second stage of labor, a woman is generally a) very aware of activities immediately around her. b) anxious to have people around her. c) no longer in need of a support person. d) turning inward to concentrate on body sensations.

A (Fetal position)

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 not affect fetal circulation during labor? a) Fetal position b) Uterine contractions c) Blood pressure d) Umbilical cord blood flow

C (In a longitudinal lie facing the left posterior Rationale: ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part.)

If a fetus is in an ROA position during labor, you would interpret this to mean the fetus is a) Presenting with the face as the presenting part b) In a common breech delivery position c) In a longitudinal lie facing the left posterior d) Facing the right anterior abdominal quadrant

D (The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.)

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: a) The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions b) Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia c) Having the woman point her toes reduces leg cramps d) The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation

D (Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps to push the fetus down. Blood flow decreases to the uterus during a contraction.)

In order to care for obstetric patients adequately, the nurse understands that labor contractions facilitate cervical dilation by: a. Contracting the lower uterine segment. b. Enlarging the internal size of the uterus. c. Promoting blood flow to the cervix. d. Pulling the cervix over the fetus and amniotic sac.

D (The endogenous endorphins released during labor will raise the woman's pain threshold and produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.)

In order to evaluate the condition of the patient accurately during labor, the nurse should be aware that: a. The woman's blood pressure will increase during contractions and fall back to prelabor normal between contractions. b. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. c. Having the woman point her toes will reduce leg cramps. d. The endogenous endorphins released during labor will raise the woman's pain threshold and produce sedation.

C (Shoulder Rationale: Shoulder presentations are the least likely to occur in less than 0.3 percent of all births. Approximately 97 percent of fetuses are in a cephalic presentation at the end of pregnancy. A longitudinal lie, in which the long axis of the fetus is parallel to the long axis of the mother, is the most common. When the fetus is in a transverse lie, the long axis of the fetus is perpendicular to the long axis of the woman. An oblique lie is in between the two.)

In preparing for the actual birth, which fetal presentation would a nurse be least likely to find? a) Transverse lie b) Breech c) Shoulder d) Oblique lie

A (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-timers; they are closer together 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.)

In relation to primary and secondary powers, the maternity nurse comprehends that: a. Primary powers are responsible for effacement and dilation of the cervix. b. Effacement generally is well ahead of dilation in women giving birth for the first time; they are closer together in subsequent pregnancies. c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. d. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

D (A decline in energy, as the body stores up for labor)

Nurses can advise their clients that all are signs that precede labor except: a) A return of urinary frequency as a result of increased bladder pressure b) Persistent low backache from relaxed pelvic joints c) Stronger and more frequent uterine (Braxton Hicks) contractions d) A decline in energy, as the body stores up for labor

B (Active: moderate, regular contractions; 4 to 7cm dilation; duration of 3 to 6 hours.)

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? a) Latent: milk, regular contractions; no dilation; blood show; duration of 2 to 4 hours b) Active: moderate, regular contractions; 4 to 7cm dilation; duration of 3 to 6 hours c) Lull: no contractions; dilation stable; duration of 20 to 60 minutes d) Transition: very strong but irregular contractions; 8 to 10cm dilation; duration of 1 to 2 hours

B (Softens cervix Rationale: The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.)

One of the theories about the onset of labor is the prostaglandin theory. While not being conclusively proven that the action of prostaglandins initiate labor, it is known that prostaglandins do play a role in labor. What is an action of prostaglandins? a) Stimulates uterine muscle to relax b) Softens cervix c) Initiates relaxation of perineum d) Initiates cervical dilation

A, C, D (Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor.)

Signs that precede labor include (Select all that apply): a. Lightening. b. Exhaustion. c. Bloody show. d. Rupture of membranes. e. Decreased fetal movement.

D (The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response.)

The factors that affect the process of labor and birth, known commonly as the five Ps, include all except: a. Passenger. b. Powers. c. Passageway. d. Pressure.

B (A woman may spend time thinking about what is happening to her. Rationale: Women need a support person with them during all stages of labor.)

The first stage of labor is often a time of introspection. In light of this, which of the following would guide your planning of nursing care? a) A woman should be left entirely alone during this period. b) A woman may spend time thinking about what is happening to her. c) No nursing care is needed to be done during this time. d) A woman will rarely speak or laugh during this period.

C (Passageway Rationale: The passageway is one of the 4 P's and involves the pelvis, both bony pelvis and the soft tissues, cervix, and vagina. The "passenger" refers to the fetus. The primary powers are the involuntary contractions of the uterus, whereas the secondary powers come from the maternal abdominal muscles. The psyche refers to the mother's mental state.)

The four essential components of labor are known as the "four P's". Which of the four P's involves the pelvis? a) Psyche b) Powers c) Passageway d) Passenger

A (Engagement Rationale: The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after delivery of the anterior and posterior shoulders.)

The initial descent of the fetus into the pelvis to zero station is which one of the cardinal movements of labor? a) Engagement b) Felxion c) Extension d) Expulsion

C (Uterine contractions during labor tend to decrease circulation through the spiral electrodes and subsequent perfusion through the intervillous space. The maternal blood supply to the placenta gradually stops with contractions. The exchange of oxygen and waste products decreases. The exchange of oxygen and waste products is affected by contractions.)

The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products: a. Continues except when placental functions are reduced. b. Increases as blood pressure decreases. c. Diminishes as the spiral arteries are compressed. d. Is not significantly affected.

B (Lie Rationale: The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.)

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. The nurse documents this finding as which of the following? a) Attitude b) Lie c) Position d) Presentation

B (The correct description of the vaginal examination for this woman in labor is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below).)

The nurse has received report regarding her patient in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and ?2-2. The nurse's interpretation of this assessment is that: a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines. b. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. c. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines. d. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.

B (Duration Rationale: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.)

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction, documenting this as which of the following? a) Peak b) Duration c) Frequency d) Intensity

C (The woman experiences a strong urge to bear down)

The nurse knows that the second stage of labor, the descent phase, has begun when: a) The amniotic membranes rupture b) The cervix cannot be felt during a vaginal examination c) The woman experiences a strong urge to bear down d) The presenting part is below the ischial spines

A (Crowning Rationale: Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.)

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which of the following? a) Crowning b) Engagement c) Descent d) Restitution

C (Ask the woman to describe why she believes that she is in labor Rationale: The nurse needs further information to assist in determining if the woman is in true or false labor. She will need to ask the patient questions to seek further assessment and triage information. Having her wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. She should continue fluid intake until it is determined whether or not she is in labor. She may be in false labor, and more information should be obtained before she is brought to the hospital.)

The nurse should initially implement which intervention when a nulliparous woman telephones the hospital to report that she is in labor. a) Emphasize that food and fluid should stop or be light b) Tell the woman to stay home until her membranes rupture c) Ask the woman to describe why she believes that she is in labor d) Arrange for the woman to come to the hospital for labor evaluation

A (During each contraction, 400 mL of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 51% above baseline pregnancy values at term. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by about 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg.)

The nurse would expect which maternal cardiovascular finding during labor? a. Increased cardiac output b. Decreased pulse rate c. Decreased white blood cell (WBC) count d. Decreased blood pressure

D ("The presenting part is at the true pelvis and is engaged." Rationale: Zero station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the patient. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.)

The patient is having a routine prenatal visit and asks the nurse what the childbirth education teacher meant when she used the term zero station. What is the best response by the nurse? 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."

B (In a first-time pregnancy, descent is usually slow but steady; in subsequent pregnancies, descent is more rapid, resulting in a shorter duration of labor. Cervical dilation is the same for all labors. Level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms is the same with all labors.)

The primary difference between the labor of a nullipara and that of a multipara is the: a. Amount of cervical dilation. b. Total duration of labor. c. Level of pain experienced. d. Sequence of labor mechanisms.

C (Molding Rationale: The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull thereby reducing the diameter of the head.)

The skull is the most important factor in relation to the labor and birth process. 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) Caput succedaneum c) Molding d) Cephalohematoma

B (Fetal head formation is called molding. Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mother's sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor.)

The slight overlapping of cranial bones or shaping of the fetal head during labor is called: a. Lightening. b. Molding. c. Ferguson reflex. d. Valsalva maneuver.

D (Globular shape to the fundus Rationale: Signs that indicate the placenta is separating from the uterine wall include a gush of blood, lengthening of the umbilical cord, and a globular shape to the fundus.)

The third stage of labor is considered to be expulsion of the placenta. This stage can last anywhere from five to 20 minutes. What is a sign that the placenta is separating from the wall of the uterus? a) Expulsion of blood clots b) Firm fundus c) Shortening of the umbilical cord d) Globular shape to the fundus

A (Third Rationale: Stage 3 begins with the birth of the baby and ends with delivery of the placenta.)

The woman has just delivered a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? a) Third b) Second c) Fourth d) First

B (Cervix Rationale: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.)

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? a) Perineum b) Cervix c) False pelvis d) Uterus

C (Cervix Rationale: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.)

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? a) Uterus b) False pelvis c) Cervix d) Perineum

A (The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.)

To care for a laboring woman adequately, the nurse understands that the __________ stage of labor varies the most in length? a. First b. Third c. Second d. Fourth

B (The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently; however, this is usually inconsistent.)

To teach patients about the process of labor adequately, the nurse knows that which event is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes

D (Fetal lie Rationale: Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.)

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? a) Fetal position b) Fetal presentation c) Fetal attitude d) Fetal lie

C (Attitude is the relation of the fetal body parts to one another. Lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relation of the presenting part to the four quadrants of the mother's pelvis.)

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: a. Lie. b. Presentation. c. Attitude. d. Position.

C, D, E (Rationale: The possible causes for the onset of labor include increase in the fetal cortisol levels, release of oxytocin by the posterior pituitary and the production of prostaglandins. Progesterone withdrawal, and not an increase, initiates labor. There is a rise in the estrogen levels at 34-35 weeks of pregnancy. Estrogen stimulates prostaglandin production and also promotes the release of oxytocin.)

When educating a group of nursing students about the theories of onset of labor, the nurse identifies which of the following factors as the possible causes for onset of labor? Select all that apply. a) Increase in the production of progesterone b) Fall in the estrogen at 34-35 weeks of pregnancy c) Prostaglandin production in the myometrium d) Increase in the fetal cortisol levels e) Release of oxytocin by the pituitary

D (Positive reinforcement Rationale: Any women, even ones who have had natural childbirth classes, have a difficult time maintaining positive coping strategies during this phase of labor. Many women describe feeling out of control during this phase of labor. A woman in transition needs support, encouragement, and positive reinforcement.)

When going through the transition phase of labor women often feel out of control. What do women in the transition phase of labor need? a) Their significant other beside them b) Intense nursing care c) Just to be left alone d) Positive reinforcement

A (Retracting of the lower segment Rationale: The nurse should identify retraction of the lower segment of the uterus as a feature of typical uterine contractions. As labor progresses the uterine contractions become stronger. The upper segment of the uterus contracts more actively than the lower segment. The lower segment retracts, pulling up the cervix. The upper segment thickens with time and the lower segment thins.)

When teaching a group of nursing students about uterine contractions, which of the following would the instructor include as a typical feature? a) Retracting of the lower segment b) Pulling down of the cervical portion c) Thinning out of the upper segment d) Contracting stronger in the lower segment

D (A platypelloid pelvis is flattened, wide, and shallow; about 3% of women have this shape. The gynecoid shape is the classical female shape, slightly ovoid and rounded; about 50% of women have this shape. An android, or malelike, pelvis is heart shaped; about 23% of women have this shape. An anthropoid, or apelike, pelvis is oval and wider; about 24% of women have this shape.)

Which basic type of pelvis includes the correct description and percentage of occurrence in women? a. Gynecoid: classic female; heart shaped; 75% b. Android: resembling the male; wider oval; 15% c. Anthropoid: resembling the ape; narrower; 10% d. Platypelloid: flattened, wide, shallow; 3%

A (Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours).)

Which description of the four stages of labor is correct for both definition and duration? a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

A, B, D, E (Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size does not affect cervical dilation.)

Which factors influence cervical dilation (Select all that apply)? a. Strong uterine contractions b. The force of the presenting fetal part against the cervix c. The size of the female pelvis d. The pressure applied by the amniotic sac e. Scarring of the cervix

C (During the active pushing (descent) phase, the woman has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The vulva stretches and begins to bulge encircling the fetal head. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.)

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

A (As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries. Cervical dilation and effacement do not occur with false labor. Lightening is the descent of the fetus toward the pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied frequently. It may slow down the descent of the fetus during labor.)

Which occurrence is associated with cervical dilation and effacement? a. Bloody show b. Lightening c. False labor d. Bladder distention

C (Beginning urge to bear down Rationale: Starting of the urge to bear down is a feature associated with the transition phase of labor. The transition phase is the last phase of the first stage of labor. In this phase the process of cervical dilatation is completed. During this phase the client experiences an increase in rectal pressure, an increase in the bloody show and an urge to bear down. The contractions are stronger and hence the client feels irritable, restless and nauseous. The client feels enthusiastic during the latent phase and not the transition phase.)

Which of the following would alert the nurse that the client is in the transition phase of labor? a) Reduction of rectal pressure b) Decrease in the bloody show c) Beginning urge to bear down d) Enthusiasm in the client

D (Allowing the woman time to be alone Rationale: Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.)

Which of the following would be least effective in promoting a positive birth outcome for a woman in labor? a) Promoting the woman's feelings of control b) Providing clear information about procedures c) Encouraging the woman to use relaxation techniques d) Allowing the woman time to be alone

C (Squatting)

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? a) Semirecumbent b) Sitting c) Squatting d) Side-lying

A (In cephalic presentations (head first), the presenting part is the occiput; this occurs in 96% of births. In a breech birth, the sacrum emerges first; this occurs in about 3% of births. In shoulder presentations, the scapula emerges first; this occurs in only 1% of births.)

Which presentation is described accurately in terms of both presenting part and frequency of occurrence? a. Cephalic: occiput; at least 95% b. Shoulder: scapula; 10% to 15% c. Breech: sacrum; 10% to 15% d. Cephalic: cranial; 80% to 85%

B (During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows pulse. It is important to monitor fetal response to contractions; however, this question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction. Vital signs are altered by contractions but are considered accurate for that period of time.)

Which statement is the best rationale for assessing maternal vital signs between contractions? a. During a contraction, assessing fetal heart rates is the priority. b. Maternal circulating blood volume increases temporarily during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate.

C (Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The "all fours" position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions.)

While providing care to a patient in active labor, the nurse should instruct the woman that: a. The supine position commonly used in the United States increases blood flow. b. The "all fours" position, on her hands and knees, is hard on her back. c. Frequent changes in position will help relieve her fatigue and increase her comfort. d. In a sitting or squatting position, her abdominal muscles will have to work harder.

C (The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal body parts to one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie.)

With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that: a. The fetal attitude describes the angle at which the fetus exits the uterus. b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother. c. The normal attitude of the fetus is called general flexion. d. The transverse lie is preferred for vaginal birth.

A (Primary powers are responsible for effacement and dilation of the cervix)

With regard to primary and secondary powers, the maternity nurse should understand that: a) Primary powers are responsible for effacement and dilation of the cervix b) Effacement generally is well ahead of dilation in women giving birth for the first time; they are more together in subsequent pregnancies c) Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation d) Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs

C (The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the baby's head; the Leopold maneuver is a means of judging descent by palpating the mother's abdomen. Restitution is the rotation of the baby's head after the infant is born.)

With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that: a. The seven critical movements must progress in a more or less orderly sequence. b. Asynclitism sometimes is achieved by means of the Leopold maneuver. c. The effects of the forces determining descent are modified by the shape of the woman's pelvis and the size of the fetal head. d. At birth the baby is said to achieve "restitution" (i.e., a return to the C-shape of the womb).

A (At the level of the umbilicus Rationale: After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts, approximately 1 cm (or fingerbreadth) each day after birth.)

Within the first hour after birth, the nurse would expect to find the woman's fundus: a) At the level of the umbilicus b) One fingerbreadth below the umbilicus c) Between the umbilicus and symphysis pubis d) 2 cm above the umbilicus