Maternity Prep-U Chapters 8,9,10

A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated?

"I will remain in my bed for my labor and birth like last time."

Which nursing action has a negative effect on fetal descent?

Administering narcotic pain medication

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking.

Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready

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

Which nursing action would the nurse anticipate doing more often for a cesarean section newborn than a vaginal birth newborn?

Upper airway suctioning

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

+4

The nurse is caring for a client in labor and notes the woman's cervix is approximately 1 cm in length. How should the nurse document this finding?

50% effaced.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA

Dilation follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement?

8 to 10 cm

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 cephalohematoma

There is no consensus of what actually happens to initiate the onset of labor. It is thought to be a combination of maternal and fetal factors that occur in such a way that labor begins. What is the term used to describe the way maternal and fetal factors interact to cause labor to begin?

Cascade effect

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

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

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie

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

The nurse is teaching a non-English speaking primigravida about the most common type of fetal presentation. Which presentation will the nurse prepare?

Cephalic presentation using preprinted materials in her language

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

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?

moderately strong contractions every 4 minutes, lasting about 1 minute

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

After pelvic measurements, a patient 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?

Passageway

During which time is the nurse correct to document the end of the third stage of labor?

At the time of placental delivery

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increased white blood cell count

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

beginning urge to bear down

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

Fetal lie

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage

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 dilatation; 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."

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

Complete cervical dilation and time of fetal birth

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize?

The completion of the third stage of labor

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?

The fetus is in the true pelvis and engaged.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

allowing the woman time to be alone

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?

degree of thinning

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:

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.

flexion internal rotation extension external rotation expulsion

A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? Select all that apply. cervical dilation of 6 cm cervical effacement of 70% strong desire to push apprehension mixed with excitement irritability with restlessness

strong desire to push irritability with restlessness

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?

Significant head molding

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

occiput