Maternity Ch. 13
The nurse is assessing a pregnant patient who is paralyzed due to a spinal injury at the level of the twelfth thoracic vertebra. Presently, she is in full-term gestation and under nursing care. What should the nurse inform the patient? 1 "You may have a prolonged labor." 2 "You may have painless uterine contractions." 3 "Your uterus may not contract due to paralysis." 4 "Your baby may develop neurologic problems."
"You may have painless uterine contractions." The pregnant patient is paralyzed due to a spinal lesion above the twelfth thoracic vertebra. In this case, the patient would not perceive the uterine contractions and thus would have painless uterine contractions. The spinal injury has no effect on the duration of labor. The uterine contractions are not dependent on any external forces, and thus this patient would have normal uterine contractions. Neurologic problems in the fetus are not a complication associated with spinal cord injury.
The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part? 1 -1 2 +1 3 +3 4 +5
+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.
While assessing a newborn immediately after vaginal birth, the mother is concerned that the newborn's head has assumed an abnormal shape. What should the nurse inform the mother of the baby? Select all that apply. A "Your baby's head should assume a normal shape within 3 days." B "Our physical therapist will be able to fix the shape of your baby's head." C "Our experienced pediatric surgeon will need to perform surgery on your baby's head." D "Applying baby oil daily for 2 weeks should help normalize the shape of your baby's head." E "This molding of the head allowed your child to adapt to the shape of your pelvis during labor."
A "Your baby's head should assume a normal shape within 3 days." E "This molding of the head allowed your child to adapt to the shape of your pelvis during labor." A change in the shape of the newborn's head during delivery due to slight overlapping of the skull bones is called molding. The shape of the head becomes normal within 3 days. Molding allows the child's head to adapt to the shape of the mother's pelvis. Physical therapy, surgery, or application of baby oil is not required to fix the shape of the newborn's head.
The nurse assisting a patient in the second stage of labor asks the patient to avoid the Valsalva maneuver. What is the effect of the Valsalva maneuver? 1 Decreases the cardiac output 2 Decreases blood pressure 3 Causes fetal hypoxia 4 Increases the pulse rate
Causes fetal hypoxia The nurse advises the patient to avoid the Valsalva maneuver for pushing during the second stageof labor, because it can result in fetal hypoxia. The Valsalva maneuver involves holding the breath and tightening the abdominal muscles. This activity increases the cardiac output and blood pressure, and the pulse rate slows down temporarily. This process is reversed when the patient takes a breath
The nurse is studying the chart of a patient in labor. If the patient's chart indicates "RMA," what is the presenting part? 1 Chin 2 Sacrum 3 Scapula 4 Occiput
Chin The chin or mentum is the presenting part of the fetus if the chart indicates "RMA." If the sacrum is the presenting part, the middle letter is S. If the scapula is the presenting part, the middle letter is Sc. If the occiput is the presenting part, the middle letter is O.
The nurse is assessing a client who is 6 months pregnant. The nurse determines that the fetus is lying in a longitudinal position with the sacrum as the presenting part and with general flexion. What fetal position should the nurse document? 1 Cephalic presentation 2 Shoulder presentation 3 Complete breech position 4 Single footling breech position
Complete breech position While assessing a pregnant client, the nurse should check the fetal lie, fetal attitude, and the presenting part in order to determine the fetal position. If the fetus lies in the longitudinal or vertical position with sacrum and feet as the presenting part and with general flexion it indicates that the fetus is in complete breech position. If the presenting part is the head instead of sacrum, then the fetus is in the cephalic position. If the fetus lies in the longitudinal or vertical position with the sacrum as the presenting part but with only one leg extended at the hip and knee, the fetus is in single footling breech.
The nurse is assessing a pregnant patient who was treated with bupivacaine (Marcaine). Which suitable intervention should the nurse perform to prevent the adverse effects of the medication? 1 Ask the patient to reduce the intake of salt. 2 Suggest that the patient change positions frequently. 3 Encourage the patient to void at least every 2 hours. 4 Cleanse the perineal area of the patient to remove any stool.
Encourage the patient to void at least every 2 hours. Bupivacaine (Marcaine) is an anesthetic drug and may cause urinary retention and bladder distention due to decreased uterine contractions (UCs). Therefore the nurse should assess the patient for the need to void and encourage her to void every 2 hours. Asking the patient to reduce the intake of salt may not prevent urinary retention. Limiting sodium is helpful in reducing blood pressure and preventing hypertension. The patient is suggested to change positions frequently when the patient's efforts are ineffective in the birthing process. The nurse should cleanse the perineal area of the patient to remove any stool, which helps decrease the risk of infection during bowel elimination. This intervention is not useful in preventing the adverse effects of anesthesia.
Which pelvic shape is most conducive to vaginal labor and birth? 1 Android 2 Gynecoid 3 Platypelloid 4 Anthropoid
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.
What intervention must the nurse perform when assisting a patient in labor who has been administered nitrous oxide for analgesia? 1 Monitor fetal heart rate (FHR) every 2 minutes. 2 Monitor maternal blood pressure every 2 minutes. 3 Instruct the patient to inhale after contraction begins. 4 Instruct the patient to breathe normally between contractions.
Instruct the patient to breathe normally between contractions. The nurse must instruct the patient to remove the mask and breathe normally between contractions. The use of nitrous oxide does not depress uterine contractions or cause adverse reactions in the fetus and newborn. The nurse need not monitor FHR or maternal blood pressure every 2 minutes. The patient must place the mask over the mouth and nose or insert the mouthpiece 30 seconds before the onset of a contraction (if regular), or as soon as a contraction begins (if irregular).
The nurse is teaching a patient, 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? 1 Involuntary contractions 2 Pain in the pelvic joints 3 100% effacement of the cervix 4 Full dilation of the cervix
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 the 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.
The nurse assisting a laboring patient recognizes the Ferguson reflex in the patient. What is the Ferguson reflex? 1 Release of endogenous oxytocin 2 Involuntary uterine contractions 3 Maternal urge to bear down 4 Mechanical stretching of the cervix
Maternal urge to bear down The maternal urge to bear down is known as the Ferguson reflex. The Ferguson reflex occurs when stretch receptors in the posterior vagina cause the 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.
What does the nurse teach a group of expectant mothers about slow-paced breathing? It is: 1 Performed at half the normal breathing rate. 2 Initiated at the onset of the first stage of labor. 3 Beneficial if performed with full concentration. 4 Repeated at the onset of the second stage of labor.
Performed at half the normal breathing rate. Slow-paced breathing is performed at approximately half the patient's normal breathing rate. It is initiated in the first stage of labor when the patient can no longer walk or talk through contractions. Patterned-pace breathing, not slow-paced breathing, is performed during the onset of the second stage of labor. Modified-paced breathing requires the patient to remain alert and concentrate more fully on breathing.
During a prenatal evaluation, the nurse notes that the patient has a flat pelvis. What term does the nurse use to refer to this type of pelvis? 1 Gynecoid 2 Android 3 Anthropoid 4 Platypelloid
Platypelloid About 3% of women may have a flat pelvis, which is referred to as a 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. An android pelvis resembles the male pelvis and may be found in 23% of women. It is heart shaped or angulated. The anthropoid pelvis resembles the pelvis of anthropoid apes and may be found in 24% of women. It is oval and wider anteroposteriorly.
What change in the cervix is most likely to be observed by the nurse if the patient presents with false labor? 1 Posterior position 2 Softened 3 Presence of effacement 4 Dilation
Posterior position False labor pain indicates an unfavorable environment for childbirth. The cervix may be in posterior position, which may not facilitate the passage open for descent of the baby. If the patient has true labor, the cervix is usually well prepared for the childbirth. The cervix becomes soft, effaced, and dilated to facilitate the descent of the baby.
After a vaginal examination, the nurse documents "RSA" on the patient's chart. What does this indicate? The presenting part is the: 1 Sacrum in the left anterior quadrant of the maternal pelvis. 2 Scapula in the right anterior quadrant of the maternal pelvis. 3 Sacrum in the right anterior quadrant of the maternal pelvis. 4 Scapula in the left transverse quadrant of the maternal pelvis.
Sacrum in the right anterior quadrant of the maternal pelvis. Fetal position is denoted by a three-letter abbreviation. The first letter denotes the location of the presenting part in the right (R) or left (L) side of the mother's pelvis. The middle letter stands for the specific presenting part of the fetus: O for occiput, S for sacrum, M for mentum, and Sc for scapula. The third letter stands for the location of the presenting part in relation to the anterior (A), posterior (P), or transverse (T) portion of the maternal pelvis. RSA indicates that the presenting part is the sacrum in the right anterior quadrant of the maternal pelvis. LSA indicates that the presenting part is the sacrum in the left anterior quadrant of the maternal pelvis. RScA shows that the presenting part is the scapula in the right anterior quadrant of the maternal pelvis. LScT indicates that the presenting part is the scapula in the left transverse quadrant of the maternal pelvis.
During the vaginal examination of a patient in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation does the nurse recognize? 1 Cephalic 2 Frank breech 3 Complete breech 4 Shoulder
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.
After a pelvic examination of a pregnant woman, the nurse concludes that the client may require a forceps-assisted delivery. What pelvic finding would support this conclusion? 1 Slightly ovoid-shaped. 2 Moderate depth. 3 Blunt ischial spines. 4 Subpubic arch is narrow.
Subpubic arch is narrow. The presence of a narrow subpubic arch indicates that the client has either an android pelvis or an anthropoid pelvis. In such situations, the fetus may not easily pass through the birth canal and the client may require a forceps-assisted delivery. The presence of a slightly ovoid pelvis with moderate depth and blunt ischial spines indicates a gynecoid pelvis. Women with gynecoid pelvises have wider subpubic arches, which allow the fetus to more easily pass through the birth canal. These clients may not require forceps-assisted deliveries.
What does the nurse teach a couple expecting their first child about the use of therapeutic touch (TT) to relieve pain during labor? 1 TT uses the concept of energy fields within the body. 2 Back massage is found to be beneficial in advanced labor. 3 TT involves the application of pressure to the patient's hips. 4 Prana are thought to be in excess in people who are in pain.
TT uses the concept of energy fields within the body. Therapeutic touch (TT) uses the concept of energy fields within the body, called prana. Specially trained persons lay hands on to redirect energy fields associated with pain. According to this concept, prana are thought to be deficient in some people who are in pain. Counterpressure is steady pressure applied by a support person to both hips to cope with the sensation of internal pressure. Hand and foot massage is found to be especially relaxing in advanced labor when hyperesthesia limits the patient's tolerance for touch on other parts of the body.
On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? 1 The fetal presenting part is 1 cm above the ischial spines. 2 Effacement is 4 cm from completion. 3 Dilation is 50% completed. 4 The fetus has achieved passage through the ischial spines.
The fetal presenting part is 1 cm above the ischial spines. Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1
The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? a. It is diamond shaped in appearance. b. It measures about 1 cm by 2 cm. c. It closes after 6 to 8 weeks of birth. d. It lies near the occipital bone.
a. 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 6 to 8 weeks after birth. It lies at the junction of the sutures of the two parietal bones and the occipital bone.
The nurse is caring for a pregnant client who is in the second stage of labor. The nurse instructs the client not to hold her breath or tighten the abdominal muscles while having intense labor pain. What is the rationale for this instruction? To prevent: 1 The onset of fetal hypoxia. 2 Maternal hypotension. 3 increased fetal heart rate. 4 Hemorrhoids in the client.
The onset of fetal hypoxia. While caring for a client who is in the second stage of the labor, the nurse should instruct the client to refrain from performing the Valsalva maneuver. During the Valsalva maneuver, the client holds her breath and tightens the abdominal muscles, which may reduce the oxygen content in the blood and cause fetal hypoxia. Tightening of the abdominal muscles increases the intrathoracic pressure and may cause hypertension in the client, but not hypotension. Due to reduced oxygen supply, the pulse rate may decrease and cause fetal bradycardia, but not tachycardia. The pressure exerted by the fetus on the vaginal wall during the delivery causes hemorrhoids, but these are not associated with the Valsalva maneuver.
What are the factors that speed up the dilation of the cervix? Select all that apply. a. Strong uterine contractions b. Scarring of the cervix c. Pressure by amniotic fluid d. Prior infection of the cervix e. Force by fetal presenting part
a. Strong uterine contractions c. Pressure by amniotic fluid e. Force by fetal presenting part Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are, in turn, 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 can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.
What response does the nurse expect when a laboring patient is administered analgesic medication early in labor? a.Painless intrauterine contractions b.Increased frequency of contractions c.Increased intensity of contractions d.Rapid descent of the fetus
a.Painless intrauterine contractions Uterine contractions are usually independent of external forces. Laboring patients who are administered analgesic medication have normal but painless uterine contractions. However, uterine contractions may decrease in frequency and intensity temporarily, if narcotic analgesic medication is administered early in labor. The first and second stages of labor are lengthened, and the rate of fetal descent slows down.
What are the factors that enable the baby to initiate respiration immediately after birth? a. Fetal respiratory movements increase during labor. b. Fetal lung fluid is cleared from the air passage. c. Arterial carbon dioxide pressure is decreased. d. Arterial pH and bicarbonate level is increased.
b. Fetal lung fluid is cleared from the air passage. Fetal lung fluid is cleared from the air passage as the infant passes through the birth canal during labor and vaginal birth. There is a decrease in fetal respiratory movements during labor. Arterial carbon dioxide pressure (Pco2) increases. There is a decrease in arterial pH and bicarbonate levels. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.
Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid
b. 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.
Concerning the third stage of labor, nurses should be aware that: 1 the placenta eventually detaches itself from a flaccid uterus. 2 the duration of the third stage may be as short as 3 to 5 minutes. 3 it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. 4 the major risk for women during the third stage is a rapid heart rate.
the duration of the third stage may be as short as 3 to 5 minutes. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The third stage of labor lasts from birth of the fetus until the placenta is delivered. 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.