Chapter 13

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

Beginning urge to bear down

A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next?

Continue to monitor the client

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 of the following?

Crowning

A nurse is caring for a client in labor who is delivering. For which fetal response should the nurse monitor?

Decrease in circulation and perfusion to the fetus

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

The initial descent of the fetus into the pelvis to zero station is which one of the cardinal movements of labor?

Engagement

A new OB/GYN physician has just finished evaluating her one hundredth patient. In reviewing the documentation from all patients thus far, which types of pelvis would you assume the physician has seen the most and the least?

Gynecoid and platypelloid, respectively

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 of the following should the nurse identify by the term presentation?

Part of the fetal body entering the maternal pelvis first

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

The woman has just delivered a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?

Third

A post delivery complete blood count (CBC) has noted an elevated white blood cell (WBC) count of 22,000/mm3. Which rationale is accurate regarding the elevated WBC count?

This is a normal variation due to stress of labor

During the second stage of labor, a woman is generally

turning inward to concentrate on body sensations.

A nurse is caring for a pregnant client during labor. Which methods should the nurse use to provide comfort to the pregnant client? Select all that apply

• Hand holding • Massaging • Acupressure

A pregnant client is admitted to a maternity clinic for childbirth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor?

It helps to rotate fetus in a posterior position.

A pregnant client is admitted to a maternity clinic for childbirth. 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

A woman is documented on the labor and delivery board to be 7cm dilated. Her family wants to know how long she will be in labor. The nurse should provide which information to the family?

"She is in active labor, she is progressing at this point and we will keep you posted."

A patient, 38 weeks gestation, pregnant with her first child calls the clinic and states "my baby is lower and it is more difficult to walk" and ask if she should come to the hospital to be checked. How should the nurse respond?

"The baby has dropped into the pelvis, your body and baby are getting ready for labor in the next few weeks."

The patient is having a routine prenatal visit and asks the nurse what the childbirth education teacher meant when she used the term zero station. What is the best response by the nurse?

"The presenting part is at the true pelvis and is engaged."

A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:

-2

Which of the following would be least effective in promoting a positive birth outcome for a woman in labor?

Allowing the woman time to be alone

The nurse should initially implement which intervention when a nulliparous woman telephones the hospital to report that she is in labor.

Ask the woman to describe why she believes that she is in labor

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

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. She 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 of the following terms 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

The RN in labor and delivery documents the fetus as ROA. To what does this documentation refer for a fetus?

Fetal position

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

The nurse is working with a patient in labor. She is happy and cheerful, and states she is "ready to see her baby." What stage or phase of labor would she anticipate the patient to be in right now?

Latent phase

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. The nurse documents this finding as which of the following?

Lie

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

Occiput

The four essential components of labor are known as the "four P's". Which of the four P's involves the pelvis?

Passageway

The five "P's" of labor are

Passageway, Passenger, Position, Powers, Psych

A 32-year-old woman presents to the labor-and-delivery 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

When teaching a group of nursing students about uterine contractions, which of the following would the instructor include as a typical feature?

Retracting of the lower segment

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 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 delivered 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.

A nurse is caring for a client in her third stage of labor. Which of the following would the nurse assess as indicating placental separation? Select all that apply

• Fresh gushing of blood from the vagina • Umbilical cord descending lower down • Renewed bearing down efforts by client

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 childbirth? Select all that apply.

• Increase in respiratory rate • Increase in blood pressure • Increase in heart rate

A nurse is assigned the task of educating a pregnant client about childbirth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive childbirth experience? Select all that apply.

• Provide the client clear information on procedures involved • Encourage the client to have a sense of mastery and self-control • Encourage the client to have a positive reaction to pregnancy