Chapter 12 Questions
The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all the he's doing now, he could tell her when the contractions are a. 2 mins apart b. at their scene c. at their increment d. at their decrement
b. at their scene rationale: when the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused.
The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient. a. on her back b. on her left side c. on her right side d. on her hands and knees
b. on her left side rationale: LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives 1. by use of gravity, the fetus will most likely stay in the LOA position 2. increase perfusion of the placenta and increase oxygen to the fetus
The primipara at 39 weeks gestation states to the nurse "I can breathe easier now". What is the nurses best response a. your labor will start any day now since the baby has dropped b. That process is called lightening. Do you have to urinate more frequently c. contact your HCP when your contractions are every 5 minutes for 1 hour d. you will likely not feel your babys movements as much now, so do not be concerned
b. that process is called lightening. Do you have to urinate more frequently
A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long a. 50 mins b. hours c. 6 to 7 hours d. 8 to 10 hours
d. 8 to 10 hours rationale: the active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 mins. The transition phase lasts hours.
To determine if the client is in true labor, the nurse would assess for changes in a. cervical dilation b. amount of bloody show c. fetal position and station d. pattern of uterine contractions.
a. cervical dilation
An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates a. Lightening b. breech presentation c. urinary tract infection d. onset of braxton hicks contractions
a. lightening rationale: as the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps
After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the best nursing action is response to this statement a. place a warm blanket over the patient b. place the baby on the patients abdomen c. tell the patient that chills are expected after birth d. what do you mean by your words "very cold"
a. place a warm blanket over the patient rationale: many women are chilled after birth.
The primary difference between labor of a nullipara and that of a multipara is a. total duration of labor b. level of pain experienced c. amount of cervical dilation d. sequence of labor mechanisms
a. total duration of labor rationale: multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter.
The HCP for a laboring patient makes the following entry into the patients record: 3/50%-1. What instruction will the nurse implement with the patient a. You will need to remain in bed attached to the electronic fetal monitor b. breathe with me slowly, in through your nose, out through your mouth c. I will begin the administration of 1000 mL of IV fluid so you can have an epidural d. your partner will need to change into scrub attire to attend the imminent birth
b. breathe with me slowly, in through your nose, out through your mouth. rationale: this client is in the latent phase of the first stage of labor.
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 mins.
b. cervical dilation and effacement rationale: the conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix.
The assessment finding which indicates that the client is in the active phase of the first stage of labor is: a. 80% effacement b. dilation of 5 cm c. presence of bloody show d. regular contraction every 3 to 4 mins
b. dilation of 5 cm rationale: active phase of labor is defined as cervical dilation between 4 to 7 cm
Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet a. extension b. engagement c. internal rotation d. external rotation
b. engagement rationale: engagement occurs when the presenting part fully enters the pelvic inlet.
A laboring patient states to the nurse "I have to push". What is the next nursing action a. Contact the HCP b. examine the patients cervix for dilation c. review with her how to bear down with contractions d. ask her partner to support her head with each push
b. examine the patients cervix for dilation rationale: when the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation
Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis a. station b. flexion c. descent d. engagement
b. flexion rationale: the anterior-posterior diameter of the head varies with how much it is flexed.
On admission to the labor and birth unit, a 38 yr old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time a. perform a vaginal exam to denote progress b. notify the HCP c. initiate parenteral therapy d. apply oxygen via nasal cannula at 8 l/min
b. notify HCP rationale: a transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated
The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase a. the client is sociable and excited b. the client is requesting pain medication c. the client begins to experience the urge to push d. the client experiences loss of control and irritability.
b. the client is requesting pain medication rationale: during the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication
The nurse should tell a primigravida that the definitive sign indicating that labor has begun is what? 1 Progressive uterine contractions with cervical change 2 Lightening 3 Rupture of membranes 4 Passage of the mucus plug (operculum
1 Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucus plug is a premonitory sign indicating that the onset of labor is getting closer.
With regard to primary and secondary powers, the maternity nurse should understand what? 1 That primary powers are responsible for effacement and dilation of the cervix 2 That effacement generally is well ahead of dilation in women giving birth for the first time; they are less together in subsequent pregnancies 3 That 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 4 That 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
1 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-time mothers; they are more concurrent 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.
When is the best time to determine the station of the presenting part in a pregnant patient? 1 When the labor begins 2 A week before the labor 3 During the fourth stage of labor 4 At the end of the third stage of labor
1 The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Birth is imminent when the presenting part is at +4 cm to +5 cm below the spine. A week before the labor is too early to determine the station because fetal descent has usually not begun. The delivery of the placenta occurs in the fourth stage of labor. Therefore, the birth process is already complete by this stage. The third stage involves the birth of the infant and ends with the expulsion of the placenta. Therefore, it is ineffective to determine the station at that point.
Which fetal attitude is seen in general flexion? Select all that apply. 1 The chin is flexed on the chest. 2 The legs are flexed at the knees. 3 The fetal head is extended. 4 The thighs are flexed on the abdomen. 5 The arms are crossed over the thorax.
1,2,4,5 Attitude or posture refers to the relation of the fetal body parts to one another. The attitude of general flexion is seen in most pregnancies. The chin is flexed on the chest, as the back of the fetus is rounded. As a result, the legs are flexed at the knees, and the thighs are flexed on the abdomen. The arms are crossed over the thorax, and the umbilical cord lies between the arms and legs. An extended fetal head indicates a deviation from the normal attitude that may cause difficulties during childbirth.
A patient has just vaginally delivered a 6-lb baby girl and the placenta. What does the fourth stage of labor entail? Select all that apply. 1 It is a crucial time for mother and newborn. 2 The fourth stage of labor is delivery of the fetus. 3 The fourth stage of labor includes delivery of the placenta. 4 The fourth stage of labor includes the first 1 to 4 hours after birth. 5 During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. 6 Mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members.
1,4,5,6 The fourth stage of labor is a crucial time for the mother and the newborn; it includes the first 1 to 2 hours after birth. During this time maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. The mother and baby are not only recovering from the physical process of birth, but are also becoming acquainted with each other and additional family members. The second (not fourth) stage of labor is delivery of the fetus. The third (not fourth) stage of labor includes delivery of the placenta.
Concerning the third stage of labor, nurses should be aware of what? 1 The placenta eventually detaches itself from a flaccid uterus. 2 The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered. 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.
2 The duration of the third stage of labor may be short. 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.
During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine 2 1 cm above the ischial spine 3 at the level of the ischial spine 4 1 cm below the ischial spine
2 When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.
Which hormone produced by the fetus is believed to initiate labor? 1 Insulin 2 Estriol 3 Cortisol 4 Thyroxine
3 The adrenal cortex is formed during the 6th week of the gestational period and produces hormones by the 8th or 9th week. The fetus produces higher amounts of cortisol as the due date gets closer. This is believed to aid in initiating labor by decreasing the maternal progesterone and stimulating prostaglandin production. Insulin, which helps regulate glucose in the fetus, is produced by the islets of Langerhans of the pancreas. Estriol is a type of estrogen hormone secreted by the placenta that stimulates uteroplacental growth. Thyroxine is a thyroid hormone produced in the fetus; thyroxine does not easily cross the placenta.
In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth
3 The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.
A pregnant woman at 40 weeks of gestation asks the nurse what factor initiates labor. What is the nurse's best response? 1 "Cervical dilation is the first step in initiating the labor process." 2 "Labor begins as a result of the increased secretion of oxytocin." 3 "One factor is higher progesterone levels, which we can mimic synthetically if labor doesn't begin soon." 4 "The exact mechanisms are unknown, but we do know that the fetus plays a role in secreting hormones that contribute to the initiation of labor."
4 The nurse's best response is, "The exact mechanisms are unknown, but we do know that the fetus plays a role in secreting hormones that contribute to the initiation of labor." Cervical dilation is not the first step in initiating the labor process. The cervix can dilate and contract throughout labor. Increased secretion of natural oxytocin appears to maintain labor once it has begun. Oxytocin alone does not appear to start labor but may play a part in labor's initiation in conjunction with other substances. The ratio of maternal estrogen to progesterone changes so that estrogen levels are higher than progesterone levels. Prostaglandins can be mimicked synthetically
A 28 yr old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 mins and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse. select all a. ask her if she thinks that her membranes have ruptured b. ask her if she has any evidence of bloody show c. have her keep monitoring her contraction pattern and call you back if they become more regular d. ask her when she has her next scheduled visit with her HCP e. tell her to come into the hospital for evaluation
a. ask her if she thinks her membranes have ruptured e. tell her to come into the hospital for evaluation
Which clinical findings would be considered to be normal for a preterm fetus during the labor period a. baseline tachycardia b. baseline bradycardia c. fetal anemia d. acidosis
a. baseline tachycardia rationale: because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system
The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions a. Assess the strongest intensity of each contraction b. assess uterine relaxation between two contractions c. assess from the beginning to the end of each contraction d. assess from the beginning of one contraction to the beginning of the next
c. assess from the beginning to the end of each contraction rationale: duration of labor contractions is the average length of contractions from beginning to end.
An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is a. onset of irregular contractions b. cephalic presentation at 0 station c. bloody mucus drainage from the vagina d. fetal heart tones (FHTs) present in the lower right quadrant
c. bloody mucus drainage from the vagina rationale: cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix
If a notation on the clients health record states that the fetal position is LSP, this means that the a. head is in the right posterior quadrant of the pelvis b. head is in the left anterior quadrant of the pelvis c. buttocks are in the left posterior quadrant of the pelvis d. buttocks are in the right upper quadrant of the abdomen
c. buttocks are in the left posterior quadrant of the pelvis rationale: LSP explains the position of the fetus in the maternal pelvis. L = left side of pelvis, S= sacrum (fetus in breech presentation), P = posterior quadrants of the pelvis
Which assessment finding would cause a concern for a client who had delivered vaginally a. estimated blood loss (EBL) of 500mL during the birth process b. white blood cell count of 28,000 postbirth c. client complains of fingers tingling d. client complains of thirst
c. client complains of fingers tingling rationale: a clients complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor.
The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction a. Is not significantly affected b. increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Continues except when placental functions are reduced
c. diminishes as the spiral arteries are compressed rationale: during labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle.
Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have a. a higher hematocrit b. increased leukocytes c. increased blood volume d. a lower fibrinogen level
c. increased blood volume rationale: women have a significant increase in blood volume during pregnancy.
A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with a. more rapid labor b. a high risk of infection c. maternal perineal trauma d. umbilical cord compression
d. umbilical cord compression rationale: the umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis.
A pregnant patient who is nearing her due date informs the nurse that she would like a vaginal delivery. The nurse observes in the medical records that the presenting part is the sacrum. What does the nurse tell the patient? 1 "Vaginal delivery may not be possible." 2 "There will be no complications during labor." 3 "You may have to lose weight for a safe delivery." 4 "The infant may have congenital physical defects
1 If the presenting part of the fetus is the sacrum, it indicates a breech presentation. Vaginal delivery of a fetus in breech position carries increased risks and it is more likely that the patient will have to have a caesarean delivery. It is inaccurate to inform the patient that there will be no complications during the birth, because this is not something that the nurse can predict. A breech presentation does not indicate that the patient needs to lose weight. Environmental and biologic factors are associated with congenital defects.
A client whose cervix is dilated to 5 cm is considered to be in which phase of labor. a. latent phase b. active phase c. second stage d. third stage
b. active phase rationale: the active phase is dilation 4 to 7 cm latent phase is true labor to 3cm second stage begins with full dilation of cervix third stage is birth of baby to expulsion of placenta
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.
1 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 is assessing a patient in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? 1 Latent phase 2 Active phase 3 Transition phase 4 Descent phase
1 The patient is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase or active pushing phase occurs in the second stage of labor. In this phase, the patient has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.
During a sterile vaginal examination, the nurse finds that the fetal position is ROA. What is the presenting part of the fetus? 1 Occiput 2 Sacrum 3 Scapula 4 Mentum
1 The presenting part of the fetus is the part that appears first during the labor. The fetal position refers to the presenting part in relation to the mother's pelvis. The position is denoted by a three-part abbreviation. In this case, the letters ROA stand for right, occiput, and anterior. It means that the occiput is the presenting part and is located in the right anterior quandrant of the maternal pelvis. Sacrum will be denoted by the letter S. Scapula (shoulder) is denoted by Sc. Mentum (chin) is denoted by the letter M.
Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1 A return of urinary frequency as a result of increased bladder pressure 2 Persistent low backache from relaxed pelvic joints 3 Stronger and more frequent uterine (Braxton Hicks) contractions 4 A decline in energy as the body stores up for labor 5 Uterus sinking downward and forward in first-time pregnancies
1,2,3,5 After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term
The nurse is assessing a pregnant patient who is due in 2 weeks. Which signs and symptoms preceding labor may the nurse expect to see in the patient? Select all that apply. 1 Loss of weight 2 Pain in the groin 3 Persistent low backache 4 Loss of energy 5 Blood-tinged cervical mucus
1,2,3,5, The pregnant patient may have a weight loss of 0.5 to 1.5 kg in the days preceding labor, due to water loss from electrolyte shifts, caused by changes in estrogen and progesterone levels. Pain in the groin and persistent low backache may occur due to the relaxation of the pelvic joints. The extreme congestion of the vaginal mucous membranes may cause blood-tinged cervical mucus. A surge of energy is a common phenomenon in a pregnant patient preceding labor
Which are the factors that affect the onset of labor? Select all that apply. 1 Increasing intrauterine pressure 2 Increasing estrogen levels 3 Decreasing oxytocin levels 4 Decreasing progesterone levels 5 Decreasing prostaglandin levels
1,2,4 Increasing intrauterine pressure, increasing estrogen levels, and decreasing progesterone levels affect the onset of labor. Increasing intrauterine pressure is associated with increasing myometrial irritability. This is caused by increasing concentrations of estrogen and decreasing progesterone levels. Oxytocin and prostaglandin levels are known to increase during the onset of labor.
When assessing a patient for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? 1 It is the part above the brim of the bony pelvis. 2 It is movable in the latter part of the pregnancy. 3 It has three planes: the inlet, midpelvis, and outlet. 4 It is ovoid and bound by pubic arch anteriorly
2 The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly
The nurse is assisting the health care provider with a patient in labor. The nurse concludes that the placental blood flow is reduced. What assessment finding would lead the nurse to conclude this? 1 Increased maternal blood pressure 2 Prolonged contractions 3 Impaired fetal respiratory movement 4 Slow decrease in progesterone levels
2 The nurse is assisting the health care provider with a patient in labor. The nurse concludes that the placental blood flow is reduced. What assessment finding would lead the nurse to conclude this? 1 Increased maternal blood pressure 2 Prolonged contractions 3 Impaired fetal respiratory movement 4 Slow decrease in progesterone levels
The nurse is assisting a patient in labor. What neurologic changes does the nurse expect in the laboring patient? 1 Decreased pain threshold 2 Amnesia and sedation 3 Increased perception of pain 4 Patient elated between contractions
2 The patient experiences amnesia between contractions in the second stage of labor. Endogenous endorphins produced by the body cause sedation. This also raises the pain threshold. Pressure of the presenting part causes physiologic anesthesia of the perineal tissues. This decreases the perception of pain. At the start of labor, the patient may be euphoric. Euphoria first gives way to increased seriousness. Second, it gives way to amnesia between contractions. Finally, it leads to elation or fatigue after giving birth.
The nurse is briefing a patient who is pregnant for the first time about "lightening." Which statement should the nurse mention to describe lightening to the patient? 1 Occurs when true labor is in progress 2 Allows the patient to breathe more easily 3 Decreases the pressure on the bladder 4 Leads to decreased urinary frequency
2 When the fetal head descends into the true pelvis during "lightening," the patient will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency.
Nurses can help their patients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Select all that apply. 1 Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours 2 Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours 3 Lull: no contractions; dilation stable; duration of 20 to 60 minutes 4 Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours 5 Full cervical dilation marks the end of the first stage of labor
2, 5 The active stage is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes. Full cervical dilation marks the end of the first stage of labor. No official "lull" phase exists in the first stage.
The nurse is assisting a pregnant patient in labor. What instructions should the nurse give to the patient to promote comfort? Select all that apply. 1 "You should cough frequently." 2 "Breathe with your mouth open." 3 "Lie down in the lateral position." 4 "Lie in the supine position in bed." 5 "Lie in the semi-Fowler's position."
2,3,5 The nurse helps the pregnant patient during labor. This includes teaching the patient relaxation techniques. The nurse teaches the patient to keep the mouth open during exhalation to allow air to easily leave the lungs. Placing the patient in a semi-Fowler's or lateral position is helpful during labor. Therefore the nurse should instruct the patient to maintain the lateral or semi-Fowler's position with a lateral tilt. Asking the patient to cough frequently would increase the intraabdominal pressure of the patient and would make the patient uncomfortable. Having the patient lie down in a supine position during labor may cause orthostatic hypotension. Therefore the nurse should instruct the patient to lie down in a position other than supine.
A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement a. the acme b. the interval c. the increment d. the decrement
a. the acme rationale: the acme is the peak or period of greatest strength during the middle of a contraction cycle.
What behavior does the nurse expect in a patient who is in the transition phase during the first stage of labor? 1 The patient remains calm and silent. 2 The patient doubts her ability to control pain. 3 The patient vomits. 4 The patient's attention is directed inward.
3 A patient in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The patient may hyperventilate, resulting in nausea and vomiting. The patient may remain calm and silent in the latent phase of uterine contractions, because the urge to bear down is not too strong in this phase. During the active stage of labor, the patient may become doubtful of her ability to control pain. The patient's attention is directed inward in the active phase of the first stage of labor.
What does the nurse know that occurs in the second stage of labor, the descent phase? 1 The amniotic membranes rupture. 2 The cervix cannot be felt during a vaginal examination. 3 The woman experiences a strong urge to bear down. 4 The presenting part is below the ischial spines.
3 During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation
The nurse assesses a fetus as being in the cephalic presentation. What does the nurse mean by the term "fetal presentation"? 1 The relation of the presenting part to the mother's pelvis 2 The relation of the fetus's and mother's spine 3 The part of the fetus that enters the pelvic inlet first 4 The relation of the fetal body parts to one another
3 Fetal presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. In a cephalic presentation, the fetal head enters the pelvic inlet first. Fetal position is the relationship of the reference point on the presenting part of the fetus to the four quadrants of the mother's pelvis. The fetal lie is the relation of the long axis or spine of the fetus to the long axis or spine of the mother. The fetal attitude is the relation of the fetal body parts to one another in utero.
A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse verifies her understanding of the instructions when the woman makes what statement? 1 "True labor contractions will subside when I walk around." 2 "True labor contractions will cause discomfort over the top of my uterus." 3 "True labor contractions will continue and get stronger even if I relax and take a shower." 4 "True labor contractions will remain irregular but become stronger."
3 True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically, the contractions often stop with walking or a change of position.
A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe what? 1 Weight gain of 1 to 3 lb 2 Quickening 3 Fatigue and lethargy 4 Bloody show
4 Passage of the mucus plug (operculum), also termed pink/bloody show, occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lb. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.
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
4 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
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
4 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.
The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement. a. Offer the client a warm blanket b. place an ice pack on the perineum c. massage the uterus if it is boggy d. delay breastfeeding until the client is rested e. explain to the client that the lochia will be light pink in color
A, B, C.
Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall. select all a. A gush of blood appears b. the uterus rises upward in the abdomen c. the fundus descends below the umbilicus d. the cord descends further from the vagina e. the uterus becomes boggy and soft, with an elongated shape
A, B, D rationale: Four Signs of Placental Separation - uterus has a spherical shape uterus rises upward in the abdomen the cord descends further from the vagina a gush of blood appears
The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the 4 Ps that interact during childbirth. select all a. powers b. passage c. position d. passenger e. psyche
A. powers, B. passage, D. passenger, E. psyche
The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session. select all a. progesterone levels become higher than estrogen levels b. natural oxytocin in conjunction with other substances plays a role c. stretching, pressure, and irritation of the uterus and cervix increase d. the secretion of prostaglandins from the fetal membranes decreases
B, C. rationale: Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labor's initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.
A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client a. This results from molding b. this results from lightening c. this results from the fetal lie d. this results from the fetal presentation
a. this results from molding rationale: the sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis.
A client asks the nurse how she can tell if labor is real. What should the nurse give as an explanation. select all. a. in true labor, the cervix begins to dilate b. in true labor, the contractions are felt in the abdomen and groin c. in true labor, contractions often resemble menstrual cramps during early labor d. in true labor, contractions are consistent in frequency, duration, and intensity in the early stages e. in true labor, your contractions tend to increase in frequency, duration, and intensity with walking.
a, c, e
Which maternal factor may inhibit fetal descent a. a full bladder b. decreased peristalsis c. rupture of membranes d. reduction in internal uterine size
a. a full bladder rationale: a full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part.
The nurse assess a laboring patients contraction pattern and notes the frequency at every 3 to 4 mins, duration 50 to 60 seconds, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern a. stage 1, latent phase b. stage 2, latent phase c. stage 1, active phase d. stage 2, active phase
c. stage 1, active phase rationale: in the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds, and an intensity that ranges from moderate to strong.
The nurse is directing an UAP to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions a. Vital signs taken during contractions are not accurate b. During a contraction, assessing fetal heart rate is the priority c. Maternal blood flow to the heart is reduced during contractions d. maternal circulating blood volume increases temporarily during contractions
d. maternal circulating blood volume increases temporarily during contractions rationale: during uterine contraction, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume.
The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by a. promoting blood flow to the cervix b. contracting the lower uterine segment c. enlarging the internal size of the uterus d. pulling the cervix over the fetus and amniotic sac
d. pulling the cervix over the fetus and amniotic sac rationale: effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward.
uncontrolled maternal hyperventilation during labor results in a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
d. respiratory alkalosis rationale: rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting is respiratory alkalosis.
