Maternity week 2 prepU
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? 90 to 140 bpm 110 to 160 bpm 100 to 150 bpm 120 to 170 bpm
110 to 160 bpm
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Maternal heart rate and blood pressure The station in which the fetus is located Maternal request for pain medication Fetal heart rate in relation to contractions
Fetal heart rate in relation to contractions
Which nursing action is a priority when the fetus is at the +4 station? Have a tocometer and a patient gown ready Provide lubricating jelly and an internal monitor Prepare for an immediate cesarean section Have a blue bulb suction and an infant warmer ready
Have a blue bulb suction and an infant warmer ready
Which is the most important nursing assessment of the mother during the fourth stage of labor? Hemorrhage Blood pressure Heart rate The mother's psyche
Hemorrhage
A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client? Contractions are stronger during the first pregnancy than the second. Braxton Hicks contractions are not strong enough during first pregnancy. The cervix takes around 12 to 16 hours to dilate during first pregnancy. Spontaneous rupture of membranes occurs during first pregnancy.
The cervix takes around 12 to 16 hours to dilate during first pregnancy.
The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the position of the fetus determining the size of the fetus determining the weight of the fetus determining the lie of the fetus determining the presentation of the fetus
determining the position of the fetus determining the presentation of the fetus determining the lie of the fetus
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 10 minutes every 5 minutes every 15 minutes every 20 minutes
every 15 minutes
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: peak. duration. frequency. intensity.
frequency.
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: left upper quadrant. left lower quadrant. right lower quadrant. right upper quadrant.
left lower quadrant.
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? position lie presentation attitude
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 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
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? brow occiput shoulders buttocks
occiput
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 about every 5 minutes. occurring in the abdomen and groin. relieved by walking.
occurring about every 5 minutes.
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 effacement of 70% apprehension mixed with excitement cervical dilation of 6 cm strong desire to push irritability with restlessness
strong desire to push irritability with restlessness
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?
3rd
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? Emphasize that food and fluid should stop or be light. Arrange for the woman to come to the hospital for labor evaluation. Ask the woman to describe why she believes that she is in labor. Tell the woman to stay home until her membranes rupture.
Ask the woman to describe why she believes that she is in labor.
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? Lasts about 20 to 25 seconds Radiates from the back to the front Occurs in an irregular pattern Slows when the woman changes position
Radiates from the back to the front
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 crowning dilatation effacement
effacement
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? breech cephalic vertex shoulder
shoulder
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth? "Do you want me to call in your family?" "Even though the baby is coming, the health care provider will be here soon." "The baby is coming. I'll explain what's happening and guide you." "The baby is coming. Relax and everything will turn out fine."
"The baby is coming. I'll explain what's happening and guide you."
A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? Notify the healthcare provider. Ask if this is the client's first pregnancy. Determine if the client is in true or false labor. Assess to see if the client has any drug allergies.
Determine if the client is in true or false labor.
A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? Hold breath for 5 seconds after every 3 breaths. Inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds. Inhale slowly through nose and exhale through pursed lips. Punctuated breathing by a forceful exhalation through pursed lips every few breaths.
Inhale slowly through nose and exhale through pursed lips.
A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor? newborn respiratory depression increased sedation nervous system depression decreased alertness
increased sedation
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Assess fetal heart rate for fetal safety. Elevate her hips to prevent cord prolapse. Ask her to bear down with the next contraction. Test a sample of amniotic fluid for protein.
Assess fetal heart rate for fetal safety.
The pain of labor is influenced by many factors. What is one of these factors? The woman has a high tolerance for pain. The woman is prepared for labor and birth. The woman has lots of visitors during labor. The woman has a high threshold for pain.
The woman is prepared for labor and birth.
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: lightening. rupture of the membranes. start of labor. placenta previa.
lightening.
A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication? ampicillin indomethacin epinephrine naloxone
naloxone
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." "It is elongated, the width is roomy, but the length is narrow." "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through."
"It is rounded in shape and allows ample room for the neonate to fit through the passageway."
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? "That is something we expect with a second or third baby, but because it is your first, you need to be checked." "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." "This is not normal unless you are in active labor; come to the hospital and be checked." "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign? "This is just a way of determining your progress in labor." "The presenting part is at the true pelvis and is engaged." "This indicates that you start labor within the next 24 hours." "This means +1 and the baby is entering the true pelvis."
"The presenting part is at the true pelvis and is engaged."
A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress? "There has been no further dilatation; effacement is progressing." "You are still 2 cm dilated, but the cervix is thinning out nicely." "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."
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? "There has been no further dilatation; effacement is progressing." "You haven't dilated any further, but hang in there; it will happen eventually." "You are still 2 cm dilated, but the cervix is thinning out nicely." 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."
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? -2 +4 0 +2
-2
The five "Ps" of labor are: passenger, position, powers, presentation, psych. passenger, position, presentation, pushing, psych. passenger, posture, position, presentation, psych. passageway, passenger, position, powers, psych.
passageway, passenger, position, powers, psych.
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? Assess amount of cervical dilation. Monitor hydration status. Monitor vital signs. Obtain urine specimen for urinalysis.
Assess amount of cervical dilation.
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? 0 to 2 3 to 4 5 to 7 8 to 10
8 to 10
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? Wrapping of the head Developmental delay A caput succedaneum A cephalohematoma
A cephalohematoma
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 cause "ripening" of the cervix. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions get closer together with activity.
Braxton Hicks contractions usually decrease in intensity with walking.
A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lbs (43 kg), and has gained 25 lbs (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment? Cannot be determined Platypelloid Android Gynecoid
Cannot be determined
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? Perineum Cervix False pelvis Uterus
Cervix
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? Bloody fluid Greenish fluid Clear to straw-colored fluid Cloudy white fluid
Clear to straw-colored fluid
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? progesterone relaxin oxytocin prolactin
relaxin
The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? Continuous support through the labor process helps decrease the need for pain medication. A quick epidural can replace the need for pain medication. Lying on an ice pack can help decrease the need for pain medication. Sitting in a hot tub helps decrease the need for pain medication.
Continuous support through the labor process helps decrease the need for pain medication.
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? Dilation of cervix Bloody show Engagement of fetus Rupture of amniotic membranes
Dilation of cervix
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? Long axis of fetus is at 60° to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is at 45° to that of client.
Long axis of fetus is perpendicular to that of client.
The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible? Molding Caput succedaneum Cephalohematoma Vertex presentation
Molding
A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. The nurse predicts the woman is close to labor based on which assessment finding? Dilation Ripening of the cervix Effacement Nesting
Nesting
When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most? Just to be left alone Intense nursing care Positive reinforcement Their significant other beside them
Positive reinforcement
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? Begin pushing as soon as the cervix has dilated to 8 cm. Push with contractions and rest between them. Pant while pushing. Hold the breath while pushing during contractions.
Push with contractions and rest between them.
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? Ensure all couples receive preconceptional genetic counseling. Reduce the rate of cesarean births among low-risk births. Ensure care during labor includes immunizations. Encourage women with previous cesareans to always have a cesarean.
Reduce the rate of cesarean births among low-risk births.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client's cervix is fully dilated. The client experiences her first full contraction. The infant is born. The client has contractions once every two minutes.
The client's cervix is fully dilated.
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? The client can be sent home. The duration of the contractions is every 5 minutes. The frequency of the contractions is every 5 minutes. The client is in active labor.
The frequency of the contractions is every 5 minutes.
The nurse is caring for four clients within the labor and delivery unit. Which client does the nurse anticipate will be sent home? The multiparous who just experienced lightening and is having contractions 7 minutes apart. The primigravid who has a thinning cervix and a dilation of 3 cm The multiparous who is effaced with dilation of 4 cm. The primigravid who is effaced, having intense contractions but at irregular intervals and dilation is 6 cm
The primigravid who has a thinning cervix and a dilation of 3 cm
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 oxytocin sensitivity. These contractions make maternal breathing easier. These contractions increase the release of prostaglandins. These contractions help in softening and ripening the cervix.
These contractions help in softening and ripening the cervix.
A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure? To prevent the woman from falling out of bed To aid the woman as she pushes during labor To decrease the heart rate of the fetus To prevent supine hypotension syndrome
To prevent supine hypotension syndrome
here has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. Women report higher levels of satisfaction when regional anesthetics are used to control pain. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
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? start of regular contractions rupturing of fetal membranes dilation of cervix diameter to 10 cm diffuse abdominal cramping
dilation of cervix diameter to 10 cm
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? intensity duration frequency peak
duration
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: effleurage. patterned breathing. therapeutic touch. acupressure.
effleurage.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a shallow deceleration occurring with the beginning of contractions variable decelerations, too unpredictable to count fetal heart rate declining late with contractions and remaining depressed fetal baseline rate increasing at least 5 mm Hg with contractions
fetal heart rate declining late with contractions and remaining depressed
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? head elevated, grasping knees, breathing out lying supine with legs in lithotomy stirrups lying on side, arms grasped on abdomen squatting while holding her breath
head elevated, grasping knees, breathing out
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? cause discomfort over the top of uterus remain irregular with the same intensity increase even if relaxing and taking a shower subside when walking around and use the lateral position
increase even if relaxing and taking a shower
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 heart rate increase in blood pressure increase in respiratory rate
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? potential placenta previa potential rapid birth of fetus increased risk of infection increased risk of breech presentation
increased risk of infection
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? reduction in length of the cervical canal effacement and dilation of the cervix shortening of the upper uterine segment restoration of blood flow to uterus and placenta
restoration of blood flow to uterus and placenta
A young couple are anxious for the birth of their child. This is the couple's first child. The nurse discusses the options, including elective induction of labor for nulliparas. The nurse determines that additional teaching is necessary when the couple identifies which condition as being associated with this procedure? postpartum hemorrhage shorter hospitalizations neonatal resuscitation increased rates of cesarean sections
shorter hospitalizations
During the second stage of labor, a woman is generally: anxious to have people around her. turning inward to concentrate on body sensations. very aware of activities immediately around her. no longer in need of a support person.
turning inward to concentrate on body sensations.