FINAL Chap 13 - Labor and Birth Process
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle? a. 8 to 12 weeks b. 4 to 6 weeks c. 14 to 8 weeks d. 12 to 14 weeks
a. 8 to 12 weeks The posterior fontanelle is a triangular-shaped area at the back of the skull. The nurse should inform the client that the posterior fontanelle normally closes by 8 to 12 weeks after birth, and if there is delay the primary health care provider should be notified.
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? a. Fourth b. Third c. First d. Second
b. Third Stage three begins with the birth of the baby and ends with delivery of the placenta.
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? a. Fourth b. Second c. First d. Third
d. Third Stage three begins with the birth of the baby and ends with delivery of the placenta.
When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanelle. Which description would the nurse include? a. approximately 2 to 3 cm in size b. closes 8 to 12 weeks after birth c. located at the back of the fetal head d. triangular shape
a. approximately 2 to 3 cm in size The anterior fontanelle measures about 2 to 3 cm in size, is diamond-shaped, and closes 12 to 18 months after birth. The posterior fontanelle is triangular and located at the back of the fetal head. The posterior fontanelle closes about 8 to 12 weeks after birth.
A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation? a. relaxin b. catecholamines c. oxytocin d. prostaglandins
b. catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? a. The perineum is relaxing b. The uterus is relaxing c. The cervix is softening d. The cervix is dilating
c. The cervix is softening The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.
Which feature would alert the nurse that the client is in the transition phase of labor? a. enthusiasm in the client b. decrease in the bloody show c. beginning urge to bear down d. reduction of rectal pressure
c. beginning urge to bear down Starting of the urge to bear down is a feature associated with the transition phase of labor. The transition phase is the last phase of the first stage of labor. In this phase the process of cervical dilatation is completed. During this phase the client experiences an increase in rectal pressure, an increase in the bloody show, and an urge to bear down. The contractions are stronger and hence the client feels irritable, restless, and nauseous. The client feels enthusiastic during the latent phase and not the transition phase.
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? a. 5 to 7 b. 0 to 2 c. 3 to 4 d. 8 to 10
d. 8 to 10 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.
The nurse is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which? a. The fetus is floating high in the pelvis. b. The client is fully effaced. c. The fetus has descended down the birth canal. d. The fetus is in the true pelvis and engaged.
d. The fetus is in the true pelvis and engaged. When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.
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: a. internal rotation, flexion, descent, extension, external rotation, expulsion. b. descent, flexion, external rotation, extension, internal rotation, expulsion. c. internal rotation, flexion, descent, extension, external rotation, expulsion. d. descent, flexion, internal rotation, extension, external rotation, expulsion.
d. descent, flexion, internal rotation, extension, external rotation, expulsion. The six cardinal movements of the fetus are descent, flexion, internal rotation, extension, external rotation, and expulsion.
Which cardinal movement of delivery is the nurse correct to document by station? a. Extension b. Internal rotation c. Flexion d. Descent
d. Descent Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.
During the second stage of labor, a woman is generally: a. very aware of activities immediately around her. b. turning inward to concentrate on body sensations. c. anxious to have people around her. d. no longer in need of a support person.
b. turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
Place the following stages of labor in order from what occurs first to last. All options must be used. 1. third stage 2. active stage 3. transition stage 4. latent stage 5. second stage
4. latent stage 2. active stage 3. transition stage 5. second stage 1. third stage The latent stage is the beginning of labor from approximately 0 cm dilated to 3 to 4 cm dilated. The active stage is from when the cervix is 4 cm dilated to 8 cm dilated. Active labor begins to become more uncomfortable for the client, and the contractions are usually stronger, longer, and closer together. Transition is approximately 8 to 10 cm. The second stage of labor is from when the client is 10 cm dilated to birth of the baby. The third stage of labor is from the birth of the baby to the delivery of the placenta.
With which findings would the nurse anticipate a diagnosis of false labor? a. Cervical dilation of 1 cm b. Softening of the cervix c. A feel of pressure in the pelvic region d. Regular contractions 8 minutes apart
a. Cervical dilation of 1 cm To be in true labor, there needs to be cervical dilation and effacement. Cervical dilation of 1 cm does not show progression in dilation as the contractions are not effective in producing further dilation. The other options could possibly be signs of true labor with cervical dilation.
The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus? a. Facing the right anterior pelvic quadrant b. Presenting with the face as the presenting part c. In a common breech birth position d. In a longitudinal lie facing the left posterior
a. Facing the right anterior pelvic quadrant ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part.
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? a. Fetal position b. Fetal attitude c. Fetal station d. Fetal size
a. Fetal position When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
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. a. Progesterone b. Prostaglandins c. Insulin d. Testosterone e. Thyroxin e. Oxytocin
a. Progesterone b. Prostaglandins e. Oxytocin There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins causes the cervix to soften and also causes the uterus to contract. Testosterone, thyroxin and insulin are not one of the main factors in the onset of labor theories.
Which client outcome during active and transitional labor is best? a. The client will practice breathing techniques during contractions. b. The client will tolerate 8 oz (224 g) of clear liquids during labor process. c. The client will walk in the hall for 15 minutes every 2 hours. d. The client will state a pain level of 7 and under during contractions.
a. The client will practice breathing techniques during contractions. The nurse identifies a priority during the active and transitional stage of labor as working with the contractions to give birth. Being tense works against cervical dilation and fetal descent. For that reason, the client is encouraged to practice breathing techniques. It may be unrealistic to state that the pain level is under 7 in the active and transitional phase. Walking in the hall and tolerating liquids also depends on the client.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? a. The client's cervix is fully dilated. b. The client has contractions once every two minutes. c. The client experiences her first full contraction. d. The infant is born.
a. The client's cervix is fully dilated. The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.
The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize? a. The completion of the third stage of labor b. The transition phase c. The client's vital signs d. The end of recovery
a. The completion of the third stage of labor The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The client's vital signs should be monitored throughout the entire process but are not the priority with the expulsion of the placenta.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? a. These contractions help in softening and ripening the cervix. b. These contractions make maternal breathing easier. c. These contractions increase the release of prostaglandins. d. These contractions increase oxytocin sensitivity.
a. These contractions help in softening and ripening the cervix. Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.
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? a. crowning b. restitution c. descent d. engagement
a. crowning 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.
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? a. effacement b. molding c. crowning d. dilatation
a. effacement 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.
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? a. pain from the dilation or stretching of the cervix b. hypoxia of the contracting uterine muscles c. distention of the vagina and perineum d. pressure on the lower back, buttocks, and thighs
a. pain from the dilation or stretching of the cervix In the first stage of labor, the primary source of pain is the dilation of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.
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? a. shoulder b. vertex c. breech d. cephalic
a. shoulder 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 multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? a. transition phase b. early phase c. latent phase d. active phase
a. transition phase The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.
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? a. "You haven't dilated any further, but hang in there; it will happen eventually." b. "You are still 2 cm dilated, but the cervix is thinning out nicely." c. Don't mention anything to the client yet; wait for further dilatation to occur. d. "There has been no further dilatation; effacement is progressing."
b. "You are still 2 cm dilated, but the cervix is thinning out nicely." Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, remember most women are aware of the word dilatation but not effacement. Just saying, "no further dilatation", therefore, 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.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? a. +1 b. +4 c. -5 d. 0
b. +4 As the fetus is being born, the station is +4. The fetus is floating and not engaged in the pelvis at -5. The fetus is at the level of the ischial spines and engaged at station 0. The fetus is progressing down the birth canal below the ischial spines at +1.
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur? a. Bloody show b. Cervical ripening and softening c. Lightening d. Braxton Hicks contractions
b. Cervical ripening and softening The ripening and softening of the cervix which result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucous plug is expelled as a result of cervical softening and increased pressure of the presenting part.
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? a. rupturing of fetal membranes b. dilation of cervix diameter to 10 cm c. diffuse abdominal cramping d. start of regular contractions
b. dilation of cervix diameter to 10 cm 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.
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur? a. Braxton Hicks contractions b. Cervical ripening and softening c. Lightening d. Bloody show
b. Cervical ripening and softening The ripening and softening of the cervix which result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucous plug is expelled as a result of cervical softening and increased pressure of the presenting part.
A primagravida has an office appointment in her 39th week of pregnancy. Which assessment data is most definitive of the onset of labor? a. The fetal head is engaged in the pelvis. b. Cervical ripening is noted on examination. c. The mother reports frequent urination. d. Expulsion of the mucous plug.
b. Cervical ripening is noted on examination. Clinical signs that labor is approaching include ripening or softening of the cervix with effacement and dilation. Frequent urination is common during engagement where the fetal head is in the pelvis. This is common up to 2 weeks before true labor begins. Expulsion of the mucous plug also is common a week or two before labor begins.
A multiparous woman at 39 weeks' gestation arrives at the labor and delivery unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix and 3 cm dilation. Which nursing action is best? a. Have the client rest in bed on her left side. b. Have the client ambulate in the hall and recheck. c. Send the client home and return if contractions increase d. Admit the client directly to the labor and delivery area
b. Have the client ambulate in the hall and recheck. To determine if the client is in true labor, the nurse is most correct to have her walk in the hall for approximately an hour. At that point, the client is rechecked to identify if labor has progressed. If labor has progressed, the client is admitted. Having the client rest in bed is not helpful to assist in labor progression.
A pregnant client is admitted to a maternity clinic for birth. 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? a. It facilitates external belt adjustment. b. It helps to rotate fetus in a posterior position. c. It helps the woman in labor to save energy. d. It facilitates vaginal examinations.
b. It helps to rotate fetus in a posterior position. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.
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? a. Long axis of fetus is at 60° to that of client. b. Long axis of fetus is perpendicular to that of client. c. Long axis of fetus is at 45° to that of client. d. Long axis of fetus is parallel to that of client.
b. Long axis of fetus is perpendicular to that of client. 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 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? a. After walking for an hour, the contractions have not fully subsided. b. The client reports back pain, and the cervix is effacing and dilating. c. The contraction pains are 2 minutes apart and 1 minute in duration. d. The contraction pains have been present for 5 hours, and the patterns are regular.
b. The client reports back pain, and the cervix is effacing and dilating. True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.
The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize? a. The client's vital signs b. The completion of the third stage of labor c. The transition phase d. The end of recovery
b. The completion of the third stage of labor The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The client's vital signs should be monitored throughout the entire process but are not the priority with the expulsion of the placenta.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? a. The client is in active labor. b. The frequency of the contractions is every 5 minutes. c. The duration of the contractions is every 5 minutes. d. The client can be sent home.
b. The frequency of the contractions is every 5 minutes. Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.
When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories? a. decrease in the level of estrogen b. change in estrogen-to-progesterone ratio c. decrease in number of oxytocin receptors d. decrease in prostaglandins, leading to myometrium contractions
b. change in estrogen-to-progesterone ratio One of the theories suggests that labor is initiated by a change in the estrogen-to-progesterone ratio. The number of oxytocin receptors have been noted to increase. Estrogen levels also increase, which in turn increases myometrial sensitivity to oxytocin. Prostaglandin levels also increase, which in turn leads to myometrial contractions.
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? a. begin and remain irregular b. increase in duration, frequency, and intensity c. felt first in lower back and sweep around to the abdomen in a wave d. often disappear with ambulation or sleep e. felt first abdominally and remain confined to the abdomen and groin f. begin irregularly but become regular and predictable
b. increase in duration, frequency, and intensity c. felt first in lower back and sweep around to the abdomen in a wave f. begin irregularly but become regular and predictable True contractions begin irregularly but become regular and predictable; are felt first in the lower back and sweep around to the abdomen in a wave; continue no matter what the woman's level of activity; increase in duration, frequency, and intensity; and achieve cervical dilatation. False (Braxton Hicks) contractions begin and remain irregular; are felt first abdominally and remain confined to the abdomen and groin; often disappear with ambulation or sleep; do not increase in duration, frequency, or intensity; and do not achieve cervical dilatation.
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. a. increase in gastric emptying and pH b. increase in respiratory rate c. slight decrease in body temperature d. increase in heart rate e. increase in blood pressure
b. increase in respiratory rate d. increase in heart rate e. increase in blood pressure 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.
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? a. increased blood coagulation time b. increased white blood cell count c. increased blood glucose levels d. decreased plasma fibrinogen levels
b. increased white blood cell count The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during 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? a. attitude b. lie c. position d. presentation
b. lie 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 five "Ps" of labor are: a. passenger, position, presentation, pushing, psych. b. passageway, passenger, position, powers, psych. c. passenger, posture, position, presentation, psych. d. passenger, position, powers, presentation, psych.
b. passageway, passenger, position, powers, psych. The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).
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? a. tight membranous attachments b. poorly ossified bones of the cranial vault c. well-ossified bones of the face d. rigid bones at the base of the skull
b. poorly ossified bones of the cranial vault Molding is an adaptive process in which there is overriding and movement of the bones of the cranial vault to adapt to the maternal pelvis. The poorly ossified bones of the cranial vault, along with loosely attached membranous attachments, allow for the process of molding in the fetal skull. The bones of the face and the base of the skull are completely ossified and united. Hence they cannot allow for movement or overriding. The membranous attachments are loosely bound to the cranial vault and not tightly, which allows for molding of the fetal skull.
After conducting a review class on the labor and birth process for a group of nurses working in the community clinic, the nurse determines that the teaching was successful when the group identifies which factors as affecting the labor process? Select all that apply. a. place b. powers c. passenger d. patience e. participation
b. powers c. passenger d. patience There are "five Ps" that affect the labor process. They are passageway, passenger, powers, position, and psychological response. There are an additional five that can also have an effect on the labor process. They include philosophy, partners, patience, client preparation, and pain control.
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? a. progesterone b. relaxin c. oxytocin d. prolactin
b. relaxin 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? a. effacement and dilation of the cervix b. restoration of blood flow to uterus and placenta c. reduction in length of the cervical canal d. shortening of the upper uterine segment
b. restoration of blood flow to uterus and placenta 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.
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? a. "She is doing well and is in the second stage; it could be anytime now." b. "She is still in early latent labor and has much too long to go to tell when she will give birth." c. "She is in active labor; she is progressing at this point and we will keep you posted." d. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner."
c. "She is in active labor; she is progressing at this point and we will keep you posted." At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.
A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting? a. Acromion process b. Occiput c. Chin d. Buttocks
d. Buttocks The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.
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? a. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital." b. "This is not normal unless you are in active labor; come to the hospital and be checked." c. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." d. "That is something we expect with a second or third baby, but because it is your first, you need to be checked."
c. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." 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.
The nurse is caring for a client who is a primagravida. Which statement is best to improve the client's psyche? a. "You will be finished soon." b. "Your second pregnancy will be easier." c. "You are doing a great job" d. "You will be pushing very soon."
c. "You are doing a great job" When a mother feels confident in her ability to cope and finds ways to work with the contractions, the labor process is enhanced. Stating that the client will be finished soon or the second pregnancy will be easier does not provide the client with confidence. Stating that the client will be pushing soon may provide the client with anxiety as she has never pushed before.
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? a. +2 b. +4 c. -2 d. 0
c. -2 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.
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is: a. 1 cm below the pubic bone. b. 1 cm below the ischial spines. c. 1 cm above the ischial spines. d. 1 cm above the pubic bone.
c. 1 cm above the ischial spines. Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and referred to as a minus or plus, depending on its location above or below the ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spine, it is recorded as plus stations. Therefore this fetus is 1 cm above the ischial spines.
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? a. Emphasize that food and fluid should stop or be light. b. Arrange for the woman to come to the hospital for labor evaluation. c. Ask the woman to describe why she believes that she is in labor. d. Tell the woman to stay home until her membranes rupture.
c. Ask the woman to describe why she believes that she is in labor. 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.
During which time is the nurse correct to document the end of the third stage of labor? a. Following fetal birth b. When pushing begins c. At the time of placental delivery d. When the mother is moved to the postpartum unit
c. At the time of placental delivery The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. The station in which the fetus is located b. Maternal heart rate and blood pressure c. Fetal heart rate in relation to contractions d. Maternal request for pain medication
c. Fetal heart rate in relation to contractions The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.
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? a. Lasts about 20 to 25 seconds b. Slows when the woman changes position c. Radiates from the back to the front d. Occurs in an irregular pattern
c. Radiates from the back to the front 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 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? a. Ensure all couples receive preconceptional genetic counseling. b. Encourage women with previous cesareans to always have a cesarean. c. Reduce the rate of cesarean births among low-risk births. d. Ensure care during labor includes immunizations.
c. Reduce the rate of cesarean births among low-risk births. 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.
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? a. Uterus b. Perineum c. False pelvis d. Cervix
d. Cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
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? a. dilatation b. molding c. effacement d. crowning
c. effacement 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.
A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor? a. second b. first, latent c. first, active d. third
c. first, active Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor, which is characterized by cervical dilation of 4 to 7 cm. Regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and at -1 station. Second stage of labor begins when the cervix is 10 cm dilated. The first latent phase is characterized by the onset of regular contractions and cervical dilation of 0 to 4 cm. Third stage of labor is from birth of the infant to completed delivery of the placenta.
The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: a. peak. b. intensity. c. frequency. d. duration.
c. frequency. Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? a. lying on side, arms grasped on abdomen b. lying supine with legs in lithotomy stirrups c. head elevated, grasping knees, breathing out d. squatting while holding her breath
c. head elevated, grasping knees, breathing out 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? a. increased risk of breech presentation b. potential rapid birth of fetus c. increased risk of infection d. potential placenta previa
c. increased risk of infection 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.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? a. brow b. buttocks c. occiput d. shoulders
c. occiput
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? a. Admission time and time of fetal birth b. Time of mucous plug expulsion and full cervical dilation c. Effacement time and time when contractions are regular d. Complete cervical dilation and time of fetal birth
d. Complete cervical dilation and time of fetal birth The second stage of labor begins with complete cervical dilation of 10 cm and ends with delivery of the neonate. All other options are incorrect time frames.
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? a. Transition phase b. Stage three c. Stage two d. Latent phase
d. Latent phase 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.
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? a. "The labor process is typically shorter for subsequent pregnancies." b. "The intensity of contractions are much greater throughout the labor." c. "You can have input into the labor plan as you know what to expect." d. "You had a successful labor and vaginal delivery with your first pregnancy."
d. "You had a successful labor and vaginal delivery with your first pregnancy." Reminding the client of her successful labor and birth best provides confidence, which strengthens a woman's psyche. It is true that subsequent pregnancies are typically shorter in length, and input in the labor plan by the multipara client can be expressed (since the woman has already experienced the process), but these are not as important as successfully completing the process. Depending upon the client's past experiences, the intensity of the contractions may or may not be more intense.
The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? a. Developmental delay b. A caput succedaneum c. Wrapping of the head d. A cephalohematoma
d. A cephalohematoma Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. Instructions for care include simple observation of the area. The cephalohematoma will subside in a couple of weeks and may take a couple of months to completely go away. There is no brain damage associated with a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.
At which point along the birth canal must the fetal head extend for successful passage? a. At the level of the ischial spines b. At the level of the iliac crest c. At the level of the pelvic inlet d. At the level of the symphysis pubis
d. At the level of the symphysis pubis Fetal extension occurs late in the labor process as the fetus extends through the final portion of the passageway. The fetal head must extend at the symphysis pubis for successful passage. The next step is the head being born. The pelvic inlet, iliac crest and ischial spines are high in the birth canal.
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? a. Vertex presentation b. Caput succedaneum c. Cephalohematoma d. Molding
d. Molding 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 nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time? a. Begin pushing as soon as the cervix has dilated to 8 cm. b. Hold the breath while pushing during contractions. c. Pant while pushing. d. Push with contractions and rest between them.
d. Push with contractions and rest between them. Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.
A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: a. a congenital defect. b. extreme pressure in the vaginal vault. c. prolonged labor. d. cranial bones overlapping at the suture lines.
d. cranial bones overlapping at the suture lines. This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor.
An OB/GYN care provider has just finished evaluating the 100th client. If the nurse could review all the documentation from each client thus far, which types of pelvis would the nurse predict the care provider has seen the most and the least? a. anthropoid and gynecoid, respectively b. gynecoid and android, respectively c. android and platypelloid, respectively d. gynecoid and platypelloid, respectively
d. gynecoid and platypelloid, respectively The gynecoid is the typical female pelvis shape, although only about half of all females have this type of pelvis. The platypelloid pelvis is the least common type of pelvis in women. Women with anthropoid pelvic shapes are able to give birth vaginally approximately one third of the time and are somewhat rare. An android pelvis is similar to a male pelvis and is seen in 16% of nonwhite women and one-third of white women.
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? a. presentation b. attitude c. position d. lie
d. lie 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.
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 description should the nurse identify by the term presentation? a. relation of the fetal presenting part to the maternal ischial spine b. relation of the different fetal body parts to one another c. relationship of the presenting part to the maternal pelvis d. part of the fetal body entering the maternal pelvis first
d. part of the fetal body entering the maternal pelvis first The term presentation is the part of the fetal body that is entering the maternal pelvis first. Relationship of the presenting part to the sides of the maternal pelvis is called the position. Attitude is the term that describes the relation of the different fetal body parts to one another. Relation of the fetal presenting part to maternal ischial spine is termed the station.
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: a. one arm is presenting. b. the fetus is sitting cross-legged above the cervix. c. one leg is presenting. d. the buttocks are presenting first with both legs extended up toward the face.
d. the buttocks are presenting first with both legs extended up toward the face. 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.