CH 12
What nursing action best helps to prevent perineal lacerations during birth? A. Providing adequate coaching on pushing and breathing B. Applying warm compresses to the perineum C. Helping the woman to squat during labor D. Performing an episiotomy early in labor
ANS: A Adequate coaching on pushing and breathing helps the woman deliver the fetal head in a controlled manner, which reduces the likelihood and/or severity of perineal lacerations. Applying warm compresses to the perineum is one of many complementary therapies used to reduce birth trauma. However, results have been inconsistent.
A woman arrives at the birthing unit complaining of frequent strong contractions that begin in her back and cannot be relieved by walking or changing positions. What action by the nurse is most appropriate? A. Assess the woman for rupture of membranes. B. Immediately notify the womans primary care provider. C. Reassure the woman and send her home. D. Review the signs of true labor with the woman.
ANS: A Distinguishing true labor from false labor can be difficult. True labor contractions occur with regularity, increased in frequency and duration, and usually begin in the womans lower back and radiate to the abdomen. Based on the womans description, the contractions likely are indicative of true labor, so she should be assessed further, including assessment for rupture of membranes. There is no urgent need to notify her primary care provider until further assessment is completed. She should not be sent home, nor does she need more education on the signs of true labor.
A nurse is caring for a new mother during the fourth stage of labor and assesses the following: patient has soaked two peri-pads in 45 minutes, pulse is 118 beats/minute, and blood pressure is 90/62 mm Hg. Which action by the nurse is most important? A. Assess the firmness of the patients uterus. B. Document the findings and reassess in 15 minutes. C. Encourage the woman to attempt breastfeeding. D. Escort the woman to the bathroom to void.
ANS: A Hypotension, tachycardia, excessive bleeding (more than one peri-pad in the first hour), and a boggy, noncontracting uterus are all danger signs of postpartum hemorrhage. Based on this womans signs and symptoms, the nurse should assess her uterus and, if necessary, begin uterine massage. Documentation needs to be thorough, but further action is needed. Breastfeeding does stimulate the uterus, but this action is not the priority in a possible emergent situation. A hypotensive woman should not be ambulated.
The nurse assesses a woman in labor and finds that her cervix is dilated to 9 cm. The nurse documents the woman to be in what phase of labor? A. First stage B. Second stage C. Third stage D. Fourth stage
ANS: A The first stage of labor begins with regular uterine contractions and ends when the cervix is fully dilated (10 cm). The second stage of labor begins with full dilation of the cervix and ends with the birth of the baby. The third stage of labor is the period of time from the birth of the baby to the complete delivery of the placenta. The fourth stage of labor is the period of maternal physiological adjustment that occurs from the time of delivery of the placenta through the first 1 to 2 hours after birth.
What important nursing action occurs right after the third stage of labor? A. Assess the placenta for complete expulsion. B. Assist the woman with effective pushing. C. Provide a lactation consultation if desired. D. Warm the baby and place it in an incubator.
ANS: A The third stage of labor is the time between the birth of the baby until the complete delivery of the placenta. An important nursing action is to assure that the entire placenta has been delivered. There is no need to assist with pushing as the baby has already been born. This is a good time to facilitate bonding and to attempt breastfeeding if desired, but too early to initiate a lactation consultation. The stable baby should be placed on the mothers abdomen.
The nurse instructs the pregnant woman to report any rupture of the membranes along with a description of the fluid. Which of the following would the nurse evaluate as normal amniotic fluid? (Select all that apply.) A. Clear liquid B. Contains white specks C. Presence of lanugo D. Slight ammonia odor E. Yellow-greenish color
ANS: A, B, C Amniotic fluid should be clear and odorless. It may contain white specks and/or fetal hair (lanugo). Yellowish-green tinged fluid may indicate infection or the presence of meconium.
The perinatal nurse obtains valuable information from a vaginal examination. Which of the following assessments from this examination should the nurse document? (Select all that apply.) A. Extent of cervical dilation B. Fetal presentation C. Presence of cervical effacement D. Status of the amniotic membranes E. Strength of uterine contractions
ANS: A, B, C, D The vaginal examination provides important information regarding the diameter of the opening of the cervix, which ranges from 1 cm (not dilated) to 10 cm (fully dilated); the status of the amniotic membranes (ruptured or intact); and the fetal presentation and the station or the extent of the fetal descent through the maternal pelvis. A trained examiner can also assess effacement of the cervix during a vaginal exam.
A nursing instructor explains to the class of nursing students that the critical factors affecting the progress of labor include which of the following? (Select all that apply.) A. Passageway B. Passageway + Passenger C. Passenger D. Productivity E. Psychosocial factors
ANS: A, B, C, E The 5 Ps of labor are Powers, Passageway, Passenger, Passageway + Passenger, and Psychosocial influences. Productivity is not included.
The perinatal nurse knows that a cephalic presentation has which of the following advantages to the woman in labor? (Select all that apply.) A. Fetal skull bones have the ability to mold during birth. B. The largest part of the fetus is presenting first. C. The presenting part may not totally cover the cervix. D. The shape of the fetal head is optimal for cervical dilatation. E. The top of the fetal head assists with cervical effacement.
ANS: A, B, D The following advantages are associated with a cephalic presentation: the fetal head is usually the largest part of the infant and after the fetal head is born, the rest of the body usually delivers without complications; the fetal head is capable of molding and there is sufficient time during labor and descent for molding of the fetal head to occur; molding helps the fetus to maneuver through the maternal birth passage; and the fetal head is smooth and round, which is the optimal shape to apply pressure to the cervix and to aid in dilation. Breech or malpresentations can lead to umbilical cord prolapse because the presenting part (e.g., a foot) may not totally cover the cervix. The presenting part does not influence effacement.
A woman in labor seems to be progressing more slowly than expected. Which action should the nurse perform first? A. Administer oxygen by face mask. B. Assess the woman for a full bladder. C. Increase the rate of the IV fluids. D. Provide stimulants such as coffee.
ANS: B A full bladder can hinder the progression of labor by slowing the descent of the fetus. A full bladder can also contribute to increased pain during contractions. The nurse should assess the woman for a full bladder. This is easy and quick to accomplish. The woman should be encouraged to void every 2 hours. The other options are not warranted.
A woman in the perinatal clinic reports a gush of vaginal fluid after sneezing. The nurse performs a Nitrazine tape test and documents that the tape is beige in color. What action should the nurse take? A. Ask the woman about recent sexual intercourse. B. Assess the woman for urinary incontinence. C. Arrange for the woman to be admitted to the birthing unit. D. Inquire if the woman has symptoms of a vaginal infection.
ANS: B Amniotic fluid is alkaline with a pH between 6.5 and 7.5. When the alkaline amniotic fluid is exposed to Nitrazine tape, the tape turns blue-green, gray, or deep blue. Urine and vaginal secretions are usually acidic. Because the gush of fluid occurred after sneezing, the nurse should assess the woman for urinary incontinence (especially stress incontinence). The presence of semen or certain bacterial infections can also lead to an alkaline result. The woman does not need admission.
A woman who is 37 weeks pregnant calls the birthing center to report a gush of clear fluid from her vagina. What response by the nurse is best? A. Are you having any pain? B. Come in now to be evaluated. C. Did you have any trauma? D. It is too early for membrane rupture.
ANS: B Any gush of fluid from a pregnant womans vagina needs to be evaluated, even if there are no contractions. The other responses are not appropriate for this situation.
A nurse assesses fetal heart tones at 100 beats/minute. Which action by the nurse takes priority? A. Administer 100% oxygen. B. Assess the maternal heart rate. C. Notify the primary care provider. D. Turn the woman on her left side.
ANS: B Causes of fetal bradycardia include late fetal hypoxia, medications (beta blockers), maternal hypotension, prolonged umbilical cord/fetal head compression, fetal bradyarrhythmias, uterine hyperstimulation, abruptio placentae, uterine rupture or vasa previa, or vagal stimulation during the second stage of labor. However, it is also possible that the maternal heart tones are mistakenly counted as fetal heart tones. The first action by the nurse is to assess the maternal heart rate to confirm that it is not being counted as the fetal heart rate. This is done whether the nurse is using a fetoscope or external fetal monitoring.
A woman who is 40 weeks pregnant calls the clinic to report that she noted a small amount of blood-tinged mucus on her toilet tissue this morning. What response by the nurse is most appropriate? A. Come to the clinic today for an examination. B. Labor will probably start within 48 hours. C. Lie on your left side and count fetal kicks. D. Stay on bedrest until your labor begins.
ANS: B During pregnancy, the cervix is plugged with mucus. When effacement begins, small capillaries can rupture, leading to an expulsion of the blood-tinged mucus plug, called bloody show. Its presence often indicates that labor will begin in 24 to 48 hours. No action is needed at this time.
A woman is in the early latent phase of labor and is frustrated by the length of time this stage is taking. What action by the nurse is best? A. Administer 100% oxygen by face mask. B. Encourage frequent position changes or walking. C. Have the woman rest between contractions. D. Place the woman in a left side-lying position.
ANS: B Frequent position changes and walking are beneficial in helping to promote the descent of the fetus during labor. The nurse should encourage the woman to try several positions (squatting, leaning over a piece of furniture, hands and knees position) and walking to try to enhance the progression of her labor. The other actions are not warranted.
A womans birthing plan includes completing the latent phase of the first stage of labor at home. When should the nurse teach the woman to come in to the birthing unit? A. After 10 hours of mild contractions B. When contractions are 3 to 5 minutes apart C. When contractions are experienced in the back D. When strong contractions occur 2 to 3 minutes apart
ANS: B The latent phase of labor is often completed at home and includes contractions that feel like menstrual cramping accompanied by low back pain. During this phase, contractions are typically 5 minutes apart, last 30 to 45 seconds, and are considered mild. This phase of labor can last up to 14 hours. However, it is not the length of time in the phase but rather the characteristics of the contractions that would signal to the woman that she is entering the active phase of labor. Strong contractions that occur 2 to 3 minutes apart indicate the transition phase of labor.
A nurse assessing fetal heart tones hears them best below the level of the maternal umbilicus. What type of fetal presentation would this nurse expect? A. Breech B. Cephalic C. Footling D. Shoulder
ANS: B Typically with a cephalic presentation, fetal heart tones will be heard best below the level of the maternal umbilicus.
The perinatal nurse knows that when the fetal head is fully extended and the occiput is near the spine, the delivery team should prepare for the presenting fetal part to be which of the following? A. Brow B. Chin C. Face D. Sacrum
ANS: C In the face presentation, the fetal head is fully extended and the occiput is near the fetal spine. The submentobregmatic diameter presents to the maternal pelvis; the face is the presenting part.
During the second stage of labor, a nurse encourages effective pushing by the woman. What directions from the nurse best achieve this? A. Hold your breath and push as hard as you can. B. Now that you are fully dilated, start pushing. C. Push when you feel the urge and breathe between attempts. D. When you feel a contraction, push with your mouth closed.
ANS: C Open-glottis pushing is the recommended technique of pushing during contractions. When the woman feels the urge to push, she is instructed to bear down while continuing to breathe between contractions. She is encouraged to only hold her breath for 5 to 6 seconds at a time so that air escapes during the pushing. This process facilitates maternalfetal circulation and gradual fetal descent. The other instructions are not consistent with this method.
A patients cervix is 8 cm dilated and she is 100% effaced. What action by the nurse is most important at this time? A. Allow the support person to be at the bedside. B. Encourage the woman to bear down. C. Have the woman avoid pushing at this time. D. Instruct the woman to rest between contractions.
ANS: C Pushing against a partially dilated cervix can lead to cervical edema and damage and can adversely affect the progress of the womans labor. It is most important to protect the patient from injury. Encouraging rest between contractions and allowing the support person at the bedside are also important, but safety comes first.
A nurse reads in a womans chart that the fetus is in a longitudinal lie. What can the nurse conclude about this situation? A. The fetal head is flexed prior to delivery. B. The fetal head-to-tailbone axis is at a 90 angle to the womans head-to-tailbone axis. C. The fetal head-to-tailbone axis is the same as the womans head-to-tailbone axis. D. Vaginal birth will be very difficult.
ANS: C The fetal lie is the relationship of the long axis of the woman to the long axis of the fetus. If the head-to-tailbone axis of the fetus is the same as the womans, the fetus is in a longitudinal lie. This occurs in more than 99% of pregnancies. Flexion of the fetal head is related to fetal attitude. When the long axis of the fetus is at a 90 angle to the long axis of the woman, it is called a transverse lie; this occurs in fewer than 1% of pregnancies.
A nurse is measuring the frequency of a laboring womans contractions. How does the nurse accomplish this correctly? A. Counts the number of contractions measured at the same intensity in 1 full minute B. Feels the fundus during the acme of the contraction and notes the fundal firmness C. Measures the beginning of one contraction to the beginning of the next contraction D. Measures the time from the beginning of one contraction to the end of the same contraction
ANS: C The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction, not by counting contractions in 1 minute. Feeling the firmness of the fundus during contractions measures intensity. Measuring the time from the start of one contraction to the end of the same contraction measures duration.
A nurse is assessing a woman in labor. In order to assess the fetal position most accurately, which of the following methods should be used? A. Auscultation of fetal heart tones B. Leopold maneuvers C. Ultrasound examination D. Vaginal examination
ANS: C Ultrasound is the most accurate way to assess the fetal position. Leopold maneuvers are not always accurate and may be clinically difficult, which also makes assessing fetal heart tones more difficult. A vaginal examination can be used, but if the membranes are still intact or if the cervix is only minimally dilated, the examiner may not be able to determine the fetuss position.
A nurse notes a perineal laceration that extends into the rectal mucosa after a woman gives birth to a full-term baby. How does the nurse document this information? A. First-degree laceration B. Second-degree laceration C. Third-degree laceration D. Fourth-degree laceration
ANS: D A fourth-degree laceration extends into the rectal mucosa and exposes the lumen of the rectum. A first-degree laceration involves only the perineal skin and vaginal mucosa. A second-degree laceration involves the skin, mucous membrane, and fascia of the perineal body. A third-degree laceration involves the skin, mucous membrane, and muscle of the perineal body and extends into the rectal sphincter.
The perinatal nurse is assessing a woman at 36 weeks gestation. Her fundal height measurement was last recorded at 34 cm. The patients abdomen appears to be widest from side to side. The nurse suspects the possibility of which type of fetal presentation? A. Breech B. Cephalic C. Face D. Shoulder
ANS: D The fetal presentation may be cephalic, breech, or shoulder. The part of the fetal body first felt by the examining finger during a vaginal examination is the presenting part. The shoulder presentation is a transverse lie. This presentation is rare and occurs in less than 1% of births. When a transverse lie is present, the maternal abdomen appears large from side to side rather than up and down. The fetal head is palpated on one maternal side and the breech is palpated on the other side. Additionally, the woman may demonstrate a lower-than-expected fundal height measurement for gestational age.
A nurse suspects that a laboring woman has entered the second stage of labor by what assessment? A. Cervix is more than 50% dilated. B. Contractions are more frequent. C. Contractions are more intense. D. Woman has a strong urge to push.
ANS: D The second stage of labor commences when the cervix is fully dilated and ends with the birth of the baby. The nurse (or woman) often suspects this has occurred when the woman has strong urges to push or has involuntary bearing-down efforts. Contractions remain similar to those experienced during transition.