Maternity Chapter 13
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? cephalic breech shoulder vertex
C 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 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 breech presentation increased risk of infection potential placenta previa potential rapid birth of fetus
B 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.
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 2030 related to women in labor? Ensure care during labor includes immunizations. Ensure all couples receive preconception genetic counseling. Reduce the rate of cesarean births among low-risk women. Encourage women with previous cesareans to always have a cesarean.
C Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.
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 reduction in length of the cervical canal shortening of the upper uterine segment effacement and dilation (dilatation) of the cervix
A 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 (dilatation) of the cervix are other processes that occur during uterine contractions.
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 position lie attitude
C 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.
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 False pelvis Perineum Uterus
A The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
A nurse is providing education to pregnant clients in birth education classes. Which nursing interventions would the nurse include to promote positive learning? Select all that apply. Encourage the clients to remain positive about the pregnancy. Provide information about all procedures in the birthing process. Instruct the class to include "self" time each day. Instruct the class to make environmental changes at home.
A B Clients should be encouraged to be positive throughout pregnancy. Providing all information about the birthing process will aid in being positive and informed. The nurse should encourage clients to have a support person. It may not be appropriate to be promote "self" time or being alone, or to change the home environment.
When going through the active phase of labor, clients often feel out of control. What intervention will help these clients best? intense nursing care positive reinforcement just to be left alone their significant other beside them
B Any client, even one who has taken natural childbirth classes, has a difficult time maintaining positive coping strategies during the active phase of labor. Many clients describe feeling out of control during this phase of labor. A client in the active phase needs support, encouragement, and positive reinforcement.
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 has descended down the birth canal. The fetus is in the true pelvis and engaged. The fetus is floating high in the pelvis.
C 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 nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Time of mucus plug expulsion and full cervical dilation Admission time and time of fetal birth Effacement time and time when contractions are regular Complete cervical dilation (dilatation) and time of fetal birth
D The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? increase in fetal oxygen pressure decrease in arterial carbon dioxide pressure increase in fetal breathing movements decrease in circulation and perfusion to the fetus
D 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.
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? buttocks occiput shoulders brow
B 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 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 chewing gum prescribed pain killers acupressure massaging
A D E To provide comfort to the pregnant client, the nurse should make use of massage, hand holding, and acupressure to bring comfort to the pregnant client during labor. It is not advisable to provide chewing gum to a client in labor; it may cause accidental asphyxiation. Pain killers are not prescribed for a client experiencing labor.
A nurse is monitoring a client in labor. Which assessment finding is most concerning to the nurse? Temperature is 101.6°F (38.7°C). Blood pressure is 128/82 mm Hg. Client begins vomiting. Respiratory rate is 22 breaths/minute.
A Although slight temperature elevations are normal during labor, a temperature of 101.6°F (38.7°C) indicates an infection and should be reported to the health care provider. As the client progresses through birth, numerous physiologic responses occur that assist the client to adapt to the laboring process. Some of these changes include heart rate increasing by 10 to 20 beats/min; blood pressure increases by up to 35 mm Hg; and respiratory rate increases as more oxygen is consumed. Nausea and vomiting are common during labor, especially during the active phase, due to decreased gastric motility.
Which cardinal movement of delivery is the nurse correct to document by station? Descent Internal rotation Flexion Extension
A 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: turning inward to concentrate on body sensations. anxious to have people around her. no longer in need of a support person. very aware of activities immediately around her.
A Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
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? Administer the medication piggybacked into a primary IV line using a pump. Assist with insertion of a central venous access device for administration. Give the medication as an intramuscular injection using the Z-track technique. Give the medication orally every hour for the first 4 hours.
A Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It is not given orally, via IM injection, or through a central venous access device.
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 of the following is an advantage of adopting a kneeling position during labor? It helps to rotate the fetus in a posterior position. It facilitates vaginal examinations. It helps the woman in labor to save energy.
A 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 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 blood pressure increase in respiratory rate slight decrease in body temperature increase in gastric emptying and pH increase in heart rate
A B E 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 systolic 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 instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. Progesterone Testosterone Prostaglandins Thyroxine Insulin Oxytocin
A C F 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 cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? lying supine with legs in lithotomy stirrups head elevated, grasping knees, breathing out squatting while holding her breath lying on side, arms grasped on abdomen
B For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. 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. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long the client will be in labor? "Your partner is doing well and is in the second stage of labor; birth could be anytime now." "Your partner is in active labor; they are progressing at this point and we will keep you posted." "Your partner is in the active phase of labor, and birth will be within 2 to 3 hours, though it might be sooner." "Your partner is still in early latent phase of labor; it is too early to estimate when they will give birth."
B At 7 cm dilated, the client is considered in the active phase of labor. There is no science that can predict the length of labor. The client is progressing in labor, and it is best that the nurse not give the family a specific time frame.
Which is the most important nursing assessment of the mother during the fourth stage of labor? The mother's psyche Hemorrhage Heart rate Blood pressure
B During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments. The mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.
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? Hold the breath while pushing during contractions. Push with contractions and rest between them. Pant while pushing. Begin pushing as soon as the cervix has dilated to 8 cm.
B 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 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? encouraging the woman to use relaxation techniques allowing the woman time to be alone promoting the woman's feelings of control providing clear information about procedures
B 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 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? stage two latent active stage three
B The client in labor undergoes numerous psychologic adaptations during labor. During the latent phase, the client is often talkative and happy, and yet anxious. During active phase, the client may show fear and anger. Both the latent and active phases occur during stage 1. During stages 2 and, the client may remain positive, but the work of labor is very intense.
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? The contraction pains are 2 minutes apart and 1 minute in duration. The client reports back pain, and the cervix is effacing and dilating. After walking for an hour, the contractions have not fully subsided. The contraction pains have been present for 5 hours, and the patterns are regular.
B 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.
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? +2 -2 0 +4
B 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.
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 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. Braxton Hicks contractions get closer together with activity.
C 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.
A nurse knows that a doula can be part of a laboring client's health care team. Which intervention would the nurse explain to the client is part of the doula's responsibility? escorting the father/partner out of the room during the labor and birth interpreting the fetal monitoring strips for fetal stability providing support and explanations during labor and birth monitoring intake and output and adjusting the IV maintenance line
C A doula provides support, encouragement, comfort measures, and explanations of the process throughout labor and birth. The doula does not replace the partner/father or provide nursing tasks during the process.
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? These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions help in softening and ripening the cervix. These contractions make maternal breathing easier.
C 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.
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 flat and narrow, making it extremely difficult for the neonate to pass through." "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." "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."
C The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid pelvis inlet allows the fetus room to pass through the dimensions of the bony passageway.
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? molding dilation (dilatation) effacement crowning
C The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilation (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 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: lasting about 30 seconds. occurring in the abdomen and groin. occurring about every 5 minutes. relieved by walking.
C 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 woman evaluated, especially if she is less than 38 weeks' pregnant.
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? "It thins to let your baby change positions during labor." "Your cervix thins so that your contractions can increase." "You need the cervix to thin so it can stretch more easily." "Cervical thinning is a sign that you are in true labor."
C The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? 0 -5 +1 +4
D As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
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? Slows when the woman changes position Lasts about 20 to 25 seconds Occurs in an irregular pattern Radiates from the back to the front
D 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 notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? restitution descent engagement crowning
D 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.
During which time is the nurse correct to document the end of the third stage of labor? Following fetal birth When pushing begins When the mother is moved to the postpartum unit At the time of placental delivery
D Explanation: 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.
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: intensity. duration. peak. frequency.
D 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.
The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? Prepare the client for cesarean birth of the fetus. Educate the client this fetal position may result in a longer labor. Auscultate fetal heart rate (FHR) in the left upper quadrant. Continue to monitor the progress of labor.
D 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. This is a common and favorable position for vaginal birth. Based on the ROA location, the nurse will auscultate FHR at the right lower quadrant of the client's abdomen (FHR will be loudest where the fetus' back is located). Occiput posterior (not anterior) positions are associated with longer, more difficult births.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client experiences her first full contraction. The client has contractions once every two minutes. The infant is born. The client's cervix is fully dilated.
D 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.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Maternal request for pain medication The station in which the fetus is located Maternal heart rate and blood pressure Fetal heart rate in relation to contractions
D 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 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 the tightening primarily in the front of my belly." "The contractions lessen after I drink a large glass of water." "I will have a strong one and then the next one will be weaker." "I feel pressure in my vagina when I have the contraction."
D True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.