Chapter 13 prep u
A primigravidia client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." Explanation: The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.
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 Explanation: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
A nulliparous client at 37 weeks gestation calls the labor and delivery unit to report she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?
Contraction, regular and lasting longer and stronger Explanation: True labor contraction will progressively get worse and last longer. The pain will come to a point where the woman will not be able to walk or talk through the contractions. Irregular contractions, bloody show, and white vaginal discharge are normal for pregnancy but do not indicate true labor.
A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?
Radiates from the back to the front Explanation: Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.
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 Explanation: The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8 to 10 Explanation: The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.
A pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:
occurring about every 5 minutes. Explanation: The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the women evaluated, especially if she is less than 38 weeks pregnant.
During the examination, the health care provider mentions the fetus has a good attitude. The nurse explains to the parents that this means:
the posture of the fetus is with all joints flexed for birth. Explanation: The attitude refers to the posturing of the joints, either flexion or extension, and the relationship of fetal parts to one another. The most common fetal attitude when labor begins is with all joints flexed. This normal fetal position is most favorable for vaginal brith, presenting the smallest fetal skull diameters to the pelvis.
The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2020 related to women in labor?
Reduce the rate of cesarean births among low-risk births. Explanation: Healthy People 2020 has two goals related to cesarean births in the United States. They are to reduce the rate of cesarean births among low-risk women and reduce the rate of cesarean births among women who have had a prior cesarean birth. Immunizations and genetic counseling are not associated with women in labor.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?
head elevated, grasping knees, breathing out Explanation: An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?
increased risk of infection Explanation: After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.
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 statement by the nurse would best encourage the client regarding her progress?
"You are still 2 cm dilated, but the cervix is thinning out nicely." Explanation: Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilatation but not effacement. Therefore, just saying, "no further dilatation" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.
During the second stage of labor, a woman is generally: in his
turning inward to concentrate on body sensations. Explanation: Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis? Select all that apply.
round-shaped inlet dull ischial spines wide pubic arch Explanation: The features of a gynecoid pelvis are oval-shaped inlet, dull ischial spines, and wide pubic arch. The birth of a baby is easiest in a gynecoid pelvis. Straight sacrum and convergent side walls are seen in an android pelvis.
When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most?
Any woman, even one who has taken natural birth classes, has a difficult time maintaining positive coping strategies during this phase of labor. Many women describe feeling out of control during this phase of labor. A woman in transition needs support, encouragement, and positive reinforcement.
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
Ask the woman to describe why she believes that she is in labor. Explanation: The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as the client may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not the client is in labor. The client may be in false labor, and more information should be obtained before the client is brought to the hospital.
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. Explanation: Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?
Engagement Explanation: The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
Fetal lie Explanation: Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?
Latent phase Explanation: The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage two she may remain positive, but the work of labor is very intense.
A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?
Long axis of fetus is perpendicular to that of client. Explanation: If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.
A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. The nurse predicts the woman is close to labor based on which assessment finding?
Nesting Explanation: Nesting is the activity or burst of energy women often experience prior to the onset of labor. The client could express this in her words or by what her activities had been at home. Dilation, effacement, and cervical ripening are all observable by the provider upon exam.
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. Explanation: Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed. You have 7
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 Explanation: The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.
The skull is the most important factor in relation to the labor and birth processes. 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?
The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.
A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?
The cervix takes around 12 to 16 hours to dilate during first pregnancy. Explanation: The labor of a first-time-pregnant woman lasts longer because during the first pregnancy the cervix takes between 12 and 16 hours to dilate completely. The intensity of the Braxton Hicks contractions stays the same during the first and second pregnancies. Spontaneous rupture of membranes may occur before the onset of labor during each birth, not only during the first birth.
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?
When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A fetus at 0 (zero) station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.
A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible?
Women should be able to move about freely throughout labor. Explanation: Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.
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 Explanation: Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?
crowning Explanation: Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?
decrease in circulation and perfusion to the fetus Explanation: When monitoring fetal responses in a client experiencing labor, the nurse should monitor for a decrease in circulation and perfusion to the fetus secondary to uterine contractions. The nurse should monitor for an increase, not a decrease, in arterial carbon dioxide pressure. The nurse should also monitor for a decrease, not an increase, in fetal breathing movements throughout labor. The nurse should monitor for a decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen.
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?
dilation of cervix diameter to 10 cm Explanation: The first stage of labor terminates with the dilation of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occurs during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.
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 Explanation: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.
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 Explanation: The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilatation refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?
increase even if relaxing and taking a shower Explanation: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.
increase in heart rate increase in blood pressure increase in respiratory rate Explanation: When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:
lightening. Explanation: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor.
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:k
lightening. Explanation: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until labor.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?
occiput Explanation: With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?
relaxin Explanation: As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth.
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?
restoration of blood flow to uterus and placenta Explanation: The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation of the cervix are other processes that occur during uterine contractions.
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?
shoulder Explanation: The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.
A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:
the buttocks are presenting first with both legs extended up toward the face. Explanation: In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.
A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?
to constrict the uterine blood vessels Explanation: The nurse must massage the client's uterus briefly after placental expulsion to constrict the uterine blood vessels and minimize the possibility of hemorrhage. Massaging the client's uterus will not lessen the chances of conducting an episiotomy. In addition, an episiotomy, if required, is conducted in the second stage of labor not the third. The client's uterus may appear boggy only in the fourth stage of labor not in the third stage. Ensuring that all sections of the placenta are present and that no piece is left attached to the uterine wall is confirmed through a placental examination after expulsion.
A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?
transverse (biparietal) Explanation: The anteroposterior diameter of the pelvis, a space approximately 11 cm wide, is the narrowest diameter at the pelvic inlet, so the best presentation for birth is when the fetus presents a transverse (biparietal) diameter (the narrowest fetal head diameter, at 9.25 cm) to this. The other diameters of the fetal skull that are listed are all larger.