Chapter 8: The Labor Process

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? First Second Third Fourth

Third

Dilation (dilatation) follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement? 3 to 4 cm 7 to 8 cm 8 to 10 cm 12 to 14 cm

8 to 10 cm

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? False pelvis Cervix Perineum Uterus

Cervix

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Admission time and time of fetal birth Complete cervical dilation (dilatation) and time of fetal birth Effacement time and time when contractions are regular Time of mucus plug expulsion and full cervical dilation

Complete cervical dilation (dilatation) and time of fetal birth

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? presentation attitude lie position

Lie

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? Longitudinal Transverse Obtuse Oblique

Longitudinal

The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. Testosterone Oxytocin Thyroxine Progesterone Prostaglandins Insulin

Prostaglandins Progesterone Oxytocin

The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth? head flexed forward so much that the chin touches the sternum chin in moderately flexed military position fetus in partial extension with brow presenting to birth canal fetus in complete extension with back arched

head flexed forward so much that the chin touches the sternum

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: latent phase of the first stage. active phase of the first stage. pelvic phase of the second stage. early phase of the third stage.

latent phase of the first stage.

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

Fetal lie

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

Occiput

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through." "It is rounded in shape and allows ample room for the neonate to fit through the passageway." "It is elongated, the width is roomy, but the length is narrow."

"It is rounded in shape and allows ample room for the neonate to fit through the passageway."

In which manner is the fetal status best assessed during the active and transition stages of labor? Fetal heart rate at the peak of a contraction Fetal movement on the tocometer Fetal heart rate between contractions Fetal kicks over a 1-minute period

Fetal heart rate at the peak of a contraction

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Fetal heart rate in relation to contractions The station in which the fetus is located Maternal heart rate and blood pressure Maternal request for pain medication

Fetal heart rate in relation to contractions

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted? platypelloid gynecoid android anthropoid

Gynecoid

Which is the most important nursing assessment of the mother during the fourth stage of labor? The mother's psyche Blood pressure Hemorrhage Heart rate

Hemorrhage

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. lightening weight gain constipation bloody show backache

lightening bloody show backache

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? "I'm feeling contractions mostly in my back." "My contractions are about 6 minutes apart and regular." "The contractions slow down when I walk around." "If I try to talk to my partner during a contraction, I can't."

"The contractions slow down when I walk around."

During which time is the nurse correct to document the end of the third stage of labor? Following fetal birth When pushing begins At the time of placental delivery When the mother is moved to the postpartum unit

At the time of placental delivery

The nurse is providing care to a pregnant woman in labor. Which components would be assessed when evaluating the passageway? Select all that apply. Bony pelvis Uterine contractions. Cervical soft tissues Fetal skull Abdominal muscle contractions

Bony pelvis Cervical soft tissues

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? extent of opening to its widest diameter degree of thinning passage of the mucous plug fetal presenting part

Degree if thinning

Which cardinal movement of delivery is the nurse correct to document by station? Descent Flexion Extension Internal rotation

Descent

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

Frank

Which nursing action is a priority when the fetus is at the +4 station? Have a blue bulb suction and an infant warmer ready. Have a tocometer and a client gown ready. Provide lubricating jelly and an internal monitor. Prepare for an immediate cesarean birth.

Have a blue bulb suction and an infant warmer ready.

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? Molding Caput succedaneum Cephalohematoma Vertex presentation

Molding

After pelvic measurements, a client who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this? powers passageway passenger psychological outlook

Passageway

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? LOA LOP ROA ROP

ROA

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? Take no extra measures; prepare for a standard labor. Anticipate this client is a one-to-one registered nursing assignment. Notify the client's support person that the labor is typically long. Prepare for vital signs and fetal monitoring hourly.

Take no extra measures; prepare for a standard labor.

Which client outcome during active and transitional labor is best? The client will state a pain level of 7 and under during contractions. The client will practice breathing techniques during contractions. The client will walk in the hall for 15 minutes every 2 hours. The client will tolerate 8 oz (240 ml) of clear liquids during labor process.

The client will practice breathing techniques during contractions.

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? The client is fully effaced. The fetus is floating high in the pelvis. The fetus is in the true pelvis and engaged. The fetus has descended down the birth canal.

The fetus is in the true pelvis and engaged

During which phase of labor would the nurse anticipate providing the most emotional support for the mother? Active phase of labor Final phase of labor Transition phase of labor Latent phase of labor

Transition phase of labor

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document? completion of the fourth stage of labor attachment phase completion of the third stage of labor transition phase

completion of the third stage of labor

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? tight membranous attachments poorly ossified bones of the cranial vault rigid bones at the base of the skull well-ossified bones of the face

poorly ossified bones of the cranial vault

A nurse is conducting an in-service program for a group of nurses working in the prenatal clinic. When discussing the theories about the onset of labor, the nurse points out which factor as a possible cause? Select all that apply. increase in the production of progesterone fall in the estrogen at 34 to 35 weeks of pregnancy decrease in the fetal cortisol levels release of oxytocin by the pituitary prostaglandin production in the myometrium

release of oxytocin by the pituitary prostaglandin production in the myometrium

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? decrease in vaginal secretions development of a membrane further closing the cervix rupture of amniotic membranes decrease in duration of contractions

rupture of amniotic membranes

The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions? number of contractions that occur in 5 minutes the end of one contraction to the beginning of the next the interval between the acmes of two consecutive contractions the interval between the beginning and the end of one contraction

the interval between the beginning and the end of one contraction

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? "I feel pressure in my vagina when I have the contraction." "I will have a strong one and then the next one will be weaker." "I feel the tightening primarily in the front of my belly." "The contractions lessen after I drink a large glass of water."

"I feel pressure in my vagina when I have the contraction."

During a visit to the prenatal clinic, a pregnant woman asks the nurse, "What causes labor to start?" Which response by the nurse would be appropriate? "Labor starts when the fetus moves into the pelvis." "Just before labor the level of the hormone oxytocin drops." "Labor starts when the uterus can't grow any further." "Labor starts from a combination of several maternal and fetal hormones working together."

"Labor starts from a combination of several maternal and fetal hormones working together."

The nurse is caring for a client who is a primigravida. Which statement is best to improve the client's psyche? "You will be finished soon." "You are doing a great job" "Your second pregnancy will be easier." "You will be pushing very soon."

"You are doing a great job."

A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours? "You are still 2 cm dilated, but the cervix is thinning out nicely." "There has been no further dilation; effacement is progressing." "You haven't dilated any further, but hang in there; it will happen eventually." Don't mention anything to the client yet; wait for further dilatation to occur.

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

When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche? "The labor process is typically shorter for subsequent pregnancies." "You can have input into the labor plan as you know what to expect." "The intensity of contractions are much greater throughout the labor." "You had a successful labor and vaginal delivery with your first pregnancy."

"You had a successful labor and vaginal delivery with your first pregnancy."

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate? "Your cervix thins so that your contractions can increase." "You need the cervix to thin so it can stretch more easily." "It thins to let your baby change positions during labor." "Cervical thinning is a sign that you are in true labor."

"Your cervix thins so that your contractions can increase."

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? -5 0 +1 +4

+4

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? +4 +2 0 -2

-2

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? -2 -1 0 +1

0

During the fourth stage of labor, which mother typically experiences the strongest afterpains? The primigravida who delivers a 6 lb (2,688 g) newborn A multipara who is breastfeeding A primigravida whose breast milk has not come in A multigravida with twins who decided to formula feed

A multipara who is breastfeeding

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? Give the medication as an intramuscular injection using the Z-track technique. Administer the medication piggybacked into a primary IV line using a pump. Give the medication orally every hour for the first 4 hours. Assist with insertion of a central venous access device for administration.

Administer the medication piggybacked into a primary IV line using a pump.

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? promoting the woman's feelings of control providing clear information about procedures allowing the woman time to be alone encouraging the woman to use relaxation techniques

Allowing the woman time to be alone

A nurse is admitting a client who presents in active labor at 41 weeks' gestation. The nurse prepares for the possibility of a cesarean delivery after noting the client has which type of pelvis documented? gynecoid anthropoid android platypelloid

Android

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 get closer together with activity. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions cause "ripening" of the cervix.

Braxton Hicks contractions usually decrease in intensity with walking

The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare? breech presentation using a picture cephalic presentation using preprinted materials in the client's language occiput presentation using a PowerPoint presentation footling presentation drawing a hand-prepared diagram

Cephalic presentation using preprinted materials in the client's language

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? regular contractions cervical dilation (dilatation) fetal movement through the birth canal placental separation

Cervical dilation (dilatation)

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? crowning effacement dilation (dilatation) molding

Effacement

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? positive reinforcement their significant other beside them intense nursing care just to be left alone

Positive reinforcement

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 Slows when the woman changes position Occurs in an irregular pattern Lasts about 20 to 25 seconds

Radiates from the back to the front

The nurse is working triage in the emergency department. The nurse realizes the client is in true labor when she states that the she is experiencing: contractions. expelling mucus plug. ruptured membranes. fetal engagement.

Ruptured membranes

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother? Thick vernix Single palmar crease Significant head molding Absence of testicular rugae

Significant head molding

In which situation would the nurse anticipate client admission to the labor and delivery unit? Select all that apply. The client is experiencing regular contractions every 5 minutes. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation). The client reports a burst of energy and completion of the nursery. Documented pelvic change from last health care provider visit. Fetal kicks noticed by the mother frequently throughout the day. The client reports a gush of fluid from the perineal region.

The client is experiencing regular contractions every 5 minutes. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation). The client reports a burst of energy and completion of the nursery. Documented pelvic change from last health care provider visit. The client reports a gush of fluid from the perineal region.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client's cervix is fully dilated. The infant is born. The client has contractions once every two minutes. The client experiences her first full contraction.

The client's cervix is fully dilated

During the second stage of labor, a woman is generally: very aware of activities immediately around her. anxious to have people around her. no longer in need of a support person. turning inward to concentrate on body sensations.

Turning inward to concentrate on bod sensations

Which nursing action would the nurse anticipate doing more often for a cesarean section newborn than a vaginal birth newborn? Monitor the temperature Assess voiding Note number of stools Upper airway suctioning

Upper airway suctioning

Which feature would alert the nurse that the client is in the transition phase of labor? reduction of rectal pressure decrease in the bloody show enthusiasm in the client beginning urge to bear down

beginning urge to bear down

A nurse is providing care to a woman in labor. The nurse determines that the client has moved into the active phase based on which assessment findings? Select all that apply. cervical dilation (dilatation) of 6 cm contractions every 1 to 2 minutes cervical effacement of 90% contractions lasting up to 60 seconds strong desire to push

cervical dilation (dilatation) of 6 cm contractions lasting up to 60 seconds

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: internal rotation, descent, extension, flexion, external rotation, expulsion descent, flexion, external rotation, extension, internal rotation, expulsion descent, flexion, internal rotation, extension, external rotation, expulsion internal rotation, flexion, descent, extension, external rotation, expulsion

descent, flexion, internal rotation, extension, external rotation, expulsion

A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. The nurse determines the session is successful when the students correctly place the following events in which order? All options must be used. internal rotation flexion extension expulsion external rotation

flexion internal rotation extension external rotation expulsion

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? decreased plasma fibrinogen levels increased blood coagulation time increased blood glucose levels increased white blood cell count

increased white blood cell count

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? is narrow transversely is ideal for birth has weaker bones than normal is "male" shaped

is narrow transversely

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? increased energy level with alternating strong and weak contractions moderately strong contractions every 4 minutes, lasting about 1 minute contractions noted in the front of abdomen that stop when she walks pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

moderately strong contractions every 4 minutes, lasting about 1 minute

The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with which? The passenger The passageway The psyche The powers

the powers

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? uterus becomes globular fetal head at vaginal opening umbilical cord shortens mucous plug is expelled

uterus becomes globular