PN108 PrepU Chapter 8

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is 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?

"The contractions slow down when I walk around."

A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why," Which response by the nurse would be most appropriate?

"You had a burst of adrenalin, which is common before labor."

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2

Assessment reveals that a woman's cervix is approximately 1 cm in length. The nurse would document this as:

50% effaced.

Dilation follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement?

8 to 10 cm

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.

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.

There is no consensus of what actually happens to initiate the onset of labor. It is thought to be a combination of maternal and fetal factors that occur in such a way that labor begins. What is the term used to describe the way maternal and fetal factors interact to cause labor to begin?

Cascade effect

The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?

Head flexed forward so much that the chin touches the sternum

A woman's body goes through many physiologic adaptations during the labor and delivery process. One of these adaptations is an increase in cardiac output. When is the cardiac output the highest?

Immediately after birth

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?

Nothing. Normal time for stage three is 5 to 30 minutes.

A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?

Push with contractions and rest between them.

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?

Say, "you are still 2 cm dilated, but the cervix is thinning out nicely."

A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull, which is the smallest, should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?

Transverse (biparietal)

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

When reviewing the history of a woman in labor, the nurse notes that the client has a funnel-shaped pelvis. How would the nurse identify this pelvic shape?

android

Which feature would alert the nurse that the client is in the transition phase of labor?

beginning urge to bear down

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation

A woman has been in labor for some time, but her membranes have not yet ruptured. Artificial rupture of membranes is being considered. Which assessment findings would support the decision to perform the procedure? Select all that apply.

cervical dilation of 4 cm fetal head at -2 station

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?

fetal lie

A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor?

increase in frequency of the contractions

When educating a group of nursing students about the theories of onset of labor, the nurse identifies which factors as the possible causes for onset of labor? Select all that apply.

increase in the fetal cortisol levels release of oxytocin by the pituitary prostaglandin production in the myometrium

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:

latent phase of the first stage.

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

After teaching a pregnant client who is in her last weeks of pregnancy about the signs and symptoms of approaching labor, which signs or symptoms if identified by the client would indicate effective teaching? Select all that apply.

lightening bloody show backache

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?

molding

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?

poorly ossified cranial vault

A pregnant woman comes to the emergency department because she thinks she is in labor. The nurse determines that the client is in true labor when assessment of contractions reveals which finding?

radiating to the front of the abdomen from the back

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?

rupture of amniotic membranes

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?

softens cervix

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?

uterus becomes globular

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?

frank

When educating a group of nursing students about the different types of pelvis, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type?

platypelloid

A nurse is caring for a pregnant client at her 34-week checkup. The client has chosen the Lamaze method for her birthing plan but states that her partner does not agree. The client says she will just change her plan. Which response by the nurse would be appropriate to support the female client?

"Have you and your partner discussed what his/her role will be in the birth?"

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?

ROA

A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor and the passage of the fetus through the birth canal. As part of the class, the nurse explains that specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse identify as being most important? Select all that apply.

Suboccipitobregmatic Biparietal

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?

cervix

During a spontaneous vaginal birth several things need to occur to the fetus in sequence. As the fetus encounters resistance, what is its usual reaction?

flexion

A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. Given in random order are a series of events that take place in a cascade to end with the birth of the baby. Arrange the series of events in the most likely sequence they occur. All options must be used.

flexion internal rotation extension restitution external rotation

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 symptom?

moderately strong contractions every 4 minutes, lasting about 1 minute

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 description should the nurse identify by the term presentation?

part of the fetal body entering the maternal pelvis first

A nurse is teaching a group of nursing students about the role of progesterone in labor. The nurse should explain that which action is the function of progesterone?

suppresses the uterine irritability throughout pregnancy