OB 13 and 14

one of the P's of labor, power has three phases which are:

Each contraction has three phases: - increment or the buildup of the contraction - acme or the peak or highest intensity - the decrement or relaxation of the uterine muscle fibers.

A pregnant client is admitted to a maternity clinic for childbirth. The client wishes to adopt the kneeling position during labor. The nurse knows that which of the following is the advantage of adopting a kneeling position during labor?

It helps to rotate the fetus in a posterior position

A pregnant client is admitted to a maternity clinic for childbirth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Long axis of fetus is perpendicular to that of client

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

Lower quadrant of the maternal abdomen

A nurse caring for a pregnant client in labor observes that the fetal heart rate is below 110 per minute. Which interventions should the nurse perform?

O2 mask

When applying the ultrasound transducers for continuous external electronic fetal monitoring, at which location would the nurse place the transducer to record the FHR? A) Over the uterine fundus where contractions are most intense B) Above the umbilicus toward the right side of the diaphragm C) Between the umbilicus and the symphysis pubis D) Between the xiphoid process and umbilicus

C. - The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. - The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

During labor, the mother experiences various physiologic responses including:

- increase in heart rate by 10 to 20 bpm - a rise in blood pressure by up to 35 mm Hg during a contraction - increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a result of tissue trauma - an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism.

The active phase of the first stage of labor is characterized by

- cervical dilation of 4 to 7 cm - effacement of 40% to 80% - contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds.

The transition phase of the first stage of labor is characterized by

- cervical dilation of 8 to 10 cm - effacement of 80% to 100% - contractions occurring every 1 to 2 minutes lasting 60 to 90 seconds.

Latent phase of labor:

- is characterized by mild contractions every 5 to 10 minutes, -cervical dilation of 0 to 3 cm - effacement of 0% to 40%, - excitement and frequent talking by the mother.

The __________ phase is characterized by strong contractions occurring every 1 to 2 minutes and cervical dilation from 8 to 10 cm.

transition

____ station is designated when the presenting part is at the level of the maternal ischial spines

zero

perpendicular line

lines that form right angles

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hick contractions. The nurse hast to educate the client on the usefulness of Braxton Hicks contractions. Which is the role of Braxton Hicks contractions in aiding labor?

these contractions help in softening and ripening the cervix

A client in the 3rd stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?

to constrict the uterine blood vessels

Oxytocin aids in stimulating prostiglandin synthesis through receptors in the _____

decidua

The thinning out process of the cervix during labor is termed what?

effacement

Braxton Hicks contractions

intermittent painless uterine contractions that occur with increasing frequency as the pregnancy progresses

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? A. External electronic fetal monitoring B. Fetal blood pH C. Fetal oxygen saturation D. Fetal position

External electronic fetal monitoring is the first option that we use

2. Which of the following would indicate to the nurse that the placenta is separating? A) Uterus becomes globular B) Fetal head is at vaginal opening C) Umbilical cord shortens D) Mucous plug is expelled

A. Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. - Expulsion of the mucous plug is a premonitory sign of labor.

_________________ contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.

Braxton-Hicks

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

C

6. A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A) Latent phase of the first stage of labor B) Active phase of the first stage of labor C) Transition phase of the first stage of labor D) Pelvic phase of the second stage of labor

C. The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control.

20. A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction? A) Heart rate increase from 76 bpm to 90 bpm B) Blood pressure rise from 110/60 mm Hg to 120/74 C) White blood cell count of 12,000 cells/mm3 D) Respiratory rate of 10 breaths /minute

D. During labor, there is an increase in respiratory rate with greater oxygen consumption due to the increase in metabolism. *A drop in respiratory rate would be a cause for concern.

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? A. Monitor vital signs B. Assess amount of cervical dilation C. Obtain urine speicmen for urinalysis D. Monitor hydration status

if vaginal bleeding is absent during admission assessment, nurse should perform vaginal examination to assess amount of cervical dilation

Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy. - Cloudy or foul-smelling amniotic fluid indicates __________ .

infection

Fetal _______________ as evidenced by a fetal heart rate greater than 160 bpm accompanied by a decrease in variability and late decelerations is an ominous sign indicating the need for prompt intervention.

tachycardia

Lightening

the sensation of the fetus moving from high in the abdomen to low in the birth canal

lightening

the sensation of the fetus moving from high in the abdomen to low in the birth canal

By the end of the second stage of labor, the nurse would expect which of the following events? The A. cervix is fully dilated and effaced B. placenta is detached and expelled C. fetus is born and on mother's chest D. woman to request pain medication

"C" because the second stage of labor is defined as beginning with complete dilation of the cervix (10 cm) and ending with the expulsion of the fetus. - Response "A" is incorrect because the cervix is fully dilated at the start of stage 2, not at the end of it. Response "

Leopold's maneuvers steps

- Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? - Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) - Maneuver 3: What is the presenting part? - Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

When does the perineal phase of the second stage occurs

- Period of active pushing - with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother.

A nurse is assigned the task of educating a pregnant client about childbirth. Which of the following nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive childbirth experience?

- Provide the client clear information on procedures involved - Encourage the client to have a sense of mastery and self-control - Encourage the client to have a positive reaction to pregancy

- Signs that the placenta is separating include:

- a firmly contracting uterus - a change in uterine shape from discoid to globular ovoid - a sudden gush of dark blood from the vaginal opening - and lengthening of the umbilical cord protruding from the vagina.

The extent of the laceration is defined by depth:

- a first-degree laceration extends through the skin - a second-degree laceration extends through the muscles of the perineal body - a third-degree laceration continues through the anal sphincter muscle - a fourth-degree laceration also involves the anterior rectal wall.

Flexion and extension are terms used to describe fetal ____________ . Cephalic is a term used to describe fetal _________ .

- attitude - presentation

A nurse is caring for a pregnant client during labor. Which of the following methods should the nurse use to provide comfort to the pregnant client? Select all

- hand holding - massaging - acupuncture

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? A. Increased sedation B. Newborn respiratory depression C. Nervous system depression D. Decreased alertness

- increase sedation is an adverse effect of lorezapam - diazepam and midazolam cause CNS depression - opiods cause newborn respiration depression

Latent phase of the first stage of labor

- involves cervical dilation of 0 to 3 cm - cervical effacement of 0% to 40%, - contractions every 5 to 10 minutes lasting 30 to 45 seconds.

Active phase of labor:

- moderate to strong contractions every 2 to 5 minutes - cervical dilation of 4 to 7 cm - effacement of 40% to 80% - with the mother becoming intense and inwardly focused.

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which of the following would the nurse expect to include when developing a plan of care for this women? (Select all that apply.) A) Administration of penicillin G at the onset of labor B) Avoidance of scalp electrodes for fetal monitoring C) Refraining from obtaining fetal scalp blood for pH testing D) Administering zidovudine at the onset of labor. E) Electing for the use of forceps-assisted delivery

-Avoidance of scalp electrodes for fetal monitoring -Refraining from obtaining fetal scalp blood for pH testing -Administering zidovudine at the onset of labor

__________ labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. ________ labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

-False -True

Which position would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? (Select all that apply.) A) Walking with partner support B) Straddling with forward leaning over a chair C) Closed knee-chest position D) Rocking back and forth with foot on chair E) Supine with legs raised at a 90-degree angle

-Walking with partner support -Straddling with forward leaning over a chair -Rocking back and forth with foot on chair

Positioning during the first stage of labor includes:

-walking with support from the partner - side-lying with pillows between the knees - leaning forward by straddling a chair, table, or bed or kneeling over a birthing ball -lunging by rocking weight back and forth with a foot up on a chair or birthing ball or an open knee-chest position.

For continuous internal electronic fetal monitoring, four criteria must be met:

1. ruptured membranes 2. cervical dilation of at least 2 cm 3. fetal presenting part low enough to allow placement of the electrode 4. skilled practitioner available to insert the electrode.

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate with the Dopplar at least how often?

30 to 60 min

The woman's temperature is typically assessed every ____ hours during the first stage of labor and every ____ hours after ruptured membranes.

4 2

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do NEXT? A. Prepare the client for birth B. Assess the client's cervical status C. notify the health care provider D. perform leopold's maneuver

5 to 6 pH means acidic environment with presence of vaginal fluid and less blood. notify provider

25. A nurse is describing how the fetus moves through the birth canal. Which of the following would the nurse identify as being most important in allowing the fetal head to move through the pelvis? A) Sutures B) Fontanelles C) Frontal bones D) Biparietal diameter

A Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. * Fontanelles are the intersections formed by the sutures.

8. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A) Latent phase of the first stage B) Active phase of the first stage C) Transition phase of the first stage D) Perineal phase of the second stage

A The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds.

The nurse notes persistent early decelerations on the fetal monitoring strip. Which of the following would the nurse do next? A) Continue to monitor the FHR because this pattern is benign. B) Perform a vaginal exam to assess cervical dilation and effacement. C) Stay with the client while reporting the finding to the physician. D) Administer oxygen after turning the client on her left side.

A Early decelerations are not indicative of fetal distress and do not require intervention. Therefore, the nurse would continue to monitor the fetal heart rate pattern. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions.

15. After teaching a group of students about the factors affecting the labor process, the instructor determines that the teaching was successful when the group identifies which of the following as a component of the true pelvis? (Select all that apply.) A) Pelvic inlet B) Cervix C) Mid pelvis D) Pelvic outlet E) Vagina F) Pelvic floor muscles

A, C, D The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

23. A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which of the following would the nurse most likely include when discussing measures to promote coping for a positive labor experience? (Select all that apply.) A) Presence of a support partner B) View of birth as a stressor C) Low anxiety level D) Fear of loss of control E) Participation in a pregnancy exercise program

A, C, E

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which of the following? A) Respiratory depression B) Urinary retention C) Abdominal distention D) Hyperreflexia

A.

24. During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate? A) "It's difficult to predict how your labor will progress, but we'll be there for you the entire time." B) "Since this is your first pregnancy, you can estimate it will be about 10 hours." C) "It will depend on how big the baby is when you go into labor."

A. It is difficult to predict how a labor will progress and therefore equally difficult to determine how long a woman's labor will last.

7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth? A) Cesarean B) Vaginal C) Forceps-assisted D) Vacuum extraction

A. The fetus is in an oblique lie with the shoulder as the presenting part, necessitating a cesarean birth.

A woman has just entered the second stage of labor. The nurse would focus care on which of the following? A) Encouraging the woman to push when she has a strong desire to do so B) Alleviating perineal discomfort with the application of ice packs C) Palpating the woman's fundus for position and firmness D) Completing the identification process of the newborn with the mother

A. During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing.

19. The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which of the following? A) Increment B) Acme C) Peak D) Decrement

A. The time from the onset to the highest intensity corresponds to the increment.

The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first? A) Feel for the fetal buttocks or head while palpating the abdomen. B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C) Palpate for the presenting part in the area just above the symphysis pubis. D) Determine flexion by pressing downward toward the symphysis pubis.

A. - The first maneuver involves feeling for the buttocks and head. - Next the nurse palpates on which side the fetal back is located. - The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. - The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

Which of the following is a priority when caring for a woman during the fourth stage of labor? A) Assessing the uterine fundus B) Offering fluids as indicated C) Encouraging the woman to void D) Assisting with perineal care

A. During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage.

A nurse palpates a woman's fundus to determine contraction intensity. Which of the following would be most appropriate for the nurse to use for palpation? A) Finger pads B) Palm of the hand C) Finger tips D) Back of the hand

A. To palpate the fundus for contraction intensity, the nurse would place the pads of the fingers on the fundus and describe how it feels.

A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful? A) "We can get up and walk around after receiving combined spinal-epidural analgesia." B) "Higher anesthetic doses are needed for patient-controlled epidural analgesia. C) "A pudendal nerve block is highly effective for pain relief in the first stage of labor." D) "Local infiltration using lidocaine is an appropriate method for controlling contraction pain."

A. When compared with traditional epidural or spinal analgesia, which often keeps the woman lying in bed, combined spinal-epidural analgesia allows the woman to ambulate ("walking epidural").

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next? A) Check the fetal heart rate. B) Perform a vaginal exam. C) Notify the physician immediately. D) Change the linen saver pad.

A. When membranes rupture, the PRIORITY focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse.

Which of the following practices would not be included in a physiologic birth? A. Early induction of labor <39 weeks' gestation B. Freedom of movement for the laboring woman C. Continuous presence and support throughout labor D. Encouraging spontaneous pushing when urge felt

A. since inducing labor artificially, rather than waiting for spontaneous labor to start doesn't provide for a physiologic birth. Nature should be allowed to take its course without artificial means to initiate labor.

Which of the following would be most appropriate for the nurse to suggest about pushing to a woman in the second stage of labor? A) "Lying flat with your head elevated on two pillows makes pushing easier." B) "Choose whatever method you feel most comfortable with for pushing." C) " Let me help you decide when it is time to start pushing." D) "Bear down like you're having a bowel movement with every contraction."

Ans. B "Choose whatever method you feel most comfortable with for pushing." * The role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push.

13. 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? A) Frank B) Full C) Complete D) Footling

Ans: A Feedback: In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

18. A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which of the following would the nurse most likely include? (Select all that apply.) A) Internal rotation B) Abduction C) Descent D) Pronation E) Flexion

Ans: A, C, E Feedback: The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.

11. After teaching a group of students about the maternal bony pelvis, which statement by the group indicates that the teaching was successful? A) The bony pelvis plays a lesser role during labor than soft tissue. B) The pelvic outlet is associated with the true pelvis. C) The false pelvis lies below the imaginary linea terminalis. D) The false pelvis is the passageway through which the fetus travels.

B The maternal bony pelvis consists of the true and false portions. The true pelvis is made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is the more important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus must travel.

9. A client is admitted to the labor and birthing suite in early labor. On review of her medical record, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A) Platypelloid B) Gynecoid C) Android D) Anthropoid

B Girl pelvis

3. When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A) Extent of opening to its widest diameter B) Degree of thinning C) Passage of the mucous plug D) Fetal presenting part

B. Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. occurs with bloody show is a .

4. 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 of the following? A) Increased energy level with alternating strong and weak contractions B) Moderately strong contractions every 4 minutes, lasting about 1 minute C) Contractions noted in the front of abdomen that stop when she walks D) Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds

B. - Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. - Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity - pink-tinged secretions with irregular contractions suggest false labor.

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which of the following would indicate the need for additional teaching? A) "This type of monitoring is the most accurate method for our baby." B) "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C) "This type of monitoring can only be used after my membranes rupture." D) "You'll be inserting a special electrode into my baby's scalp."

B. With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. *Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes.

21. When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage? A) Regular contractions B) Cervical dilation C) Fetal movement through the birth canal D) Placental separation

B. The primary change occurring during the first stage of labor is progressive cervical dilation.

10. A woman telephones her health care provider and reports that her "water just broke." Which suggestion by the nurse would be most appropriate? A) "Call us back when you start having contractions." B) "Come to the clinic or emergency department for an evaluation." C) "Drink 3 to 4 glasses of water and lie down." D) "Come in as soon as you feel the urge to push."

B. When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman's medical record to ensure which of the following as being required? A) Intact membranes B) Cervical dilation of 2 cm or more C) Floating presenting fetal part D) A neonatologist to insert the electrode

B. For continuous internal electronic fetal monitoring, four criteria must be met: 1. ruptured membranes 2. cervical dilation of at least 2 cm 3. fetal presenting part low enough to allow placement of the electrode 4. skilled practitioner available to insert the electrode.

14. A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which of the following has most likely occurred? A) Cervical dilation B) Lightening C) Bloody show D) Braxton-Hicks contractions

B. Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. * Although cervical dilation also may be occurring, it does not account for the woman's complaints. * Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor.

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which of the following? A) Early decelerations B) Variable decelerations C) Prolonged decelerations D) Late decelerations

B. Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns.

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which of the following? A) Skin B) Muscles of perineal body C) Anal sphincter D) Anterior rectal wall

B. Muscle of perineal body

26. Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A) -2 B) -1 C) 0 D) +1

C.

When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? A) Every 2 to 4 hours B) Every 45 to 60 minutes C) Every 15 to 30 minutes D) Every 10 to 15 minutes

C. During the active phase of labor, FHR is monitored every 15 to 30 minutes.

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A) Butorphanol B) Fentanyl C) Naloxone D) Promethazine

C. Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression.

5. A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A) Supine B) Lithotomy C) Upright D) Knee-chest

C. The use of any upright position helps to reduce the length of labor. - The knee-chest position would assist in rotating the fetus in a posterior position.

17. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which of the following is the presenting part? A) Occiput B) Face C) Buttocks D) Shoulder

C. - The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. - The letter "O" would denote the occiput or vertex presentation. - The letter "M" would denote the mentum (chin) or face presentation. - The letter "A" would denote the acromion or shoulder presentation.

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A) Intense B) Strong C) Moderate D) Mild

C. -A contraction that feels like the chin typically represents a moderate contraction. -A contraction described as feeling like the tip of the nose indicates a mild contraction. - A strong contraction feels like the forehead.

A nurse is assisting with the delivery of a newborn. The fetal head has just emerged. Which of the following would be done next? A) Suctioning of the mouth and nose B) Clamping of the umbilical cord C) Checking for the cord around the neck D) Drying of the newborn

C. Checking for the cord around the neck once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. * Then the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium.

The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? A. Reposition the client on the left side. B. Begin 100% oxygen via face mask. C. Document this as indicating a normal pattern. D. Call the health care provider immediately.

C. Fetal accelerations denote an intact central nervous system and appropriate oxygenation levels demonstrated by an increase in heart rate associated with fetal movement. Accelerations are a reassuring pattern, so no intervention is needed.

16. A nurse is documenting fetal lie of a woman in labor. Which term would the nurse most likely use? A) Flexion B) Extension C) Longitudinal D) Cephalic

C. Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. primary lies: longitudinal, transverse and oblique.

When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm, accompanied by a decrease in variability and late decelerations. Which of the following would the nurse do next? A) Have the woman change her position. B) Administer oxygen. C) Notify the health care provider. D) Continue to monitor the pattern every 15 minutes.

C. Fetal tachycardia as evidenced by a fetal heart rate greater than 160 bpm accompanied by a decrease in variability and late decelerations is an ominous sign indicating the need for prompt intervention. The health care provider should be notified immediately and then measures should be instituted such as having the woman lie on her side and administering oxygen.

A nurse is providing care to a woman during the third stage of labor. Which of the following would alert the nurse that the placenta is separating? A) Boggy, soft uterus B) Uterus becoming discoid shaped C) Sudden gush of dark blood from the vagina D) Shortening of the umbilical cord

C. Sudden gush of dark blood from the vagina

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A) +2 station B) 0 station C) -2 station D) Crowning

C. The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station.

A nurse is explaining the use of therapeutic touch as a pain relief measure during labor. Which of the following would the nurse include in the explanation? A) "This technique focuses on manipulating body tissues." B) "The technique requires focusing on a specific stimulus." C) "This technique redirects energy fields that lead to pain." D) "The technique involves light stroking of the abdomen with breathing."

C. "This technique redirects energy fields that lead to pain." -Therapeutic touch is an energy therapy and is based on the premise that the body contains energy fields that lead to either good or ill health and that the hands can be used to redirect the energy fields that lead to pain. - Attention focusing and imagery involve focusing on a specific stimulus. - Massage focuses on manipulating body tissues. - Effleurage involves light stroking of the abdomen in rhythm with breathing.

12. A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as: A) +4 B) +2 C) 0 D) -2

D.

22. A nurse is caring for several women in labor. The nurse determines that which woman is in the transition phase of labor? A) Contractions every 5 minutes, cervical dilation 3 cm B) Contractions every 3 minutes, cervical dilation 5 cm C) Contractions every 21/2 minutes, cervical dilation 7 cm D) Contractions every 1 minute, cervical dilation 9 cm

D. The transition phase is characterized by strong contractions occurring every 1 to 2 minutes and cervical dilation from 8 to 10 cm.

A client states, "I think my waters broke! I felt this gush of fluid between my legs." The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the paper turns: A) Yellow B) Olive green C) Pink D) Blue

D. Amniotic fluid is alkaline and turns Nitrazine paper blue. * Nitrazine paper that remains yellow to olive green suggests that the membranes are most likely intact.

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A) "The warmth and buoyancy of the water has a nice relaxing effect." B) "I can stay in the bath for as long as I feel comfortable." C) "My cervix should be dilated more than 5 cm before I try using this method." D) "The temperature of the water should be at least 105°F."

D. The water temperature should not exceed body temperature. Therefore, a temperature of 105° F would be too warm.

A group of nursing students are reviewing the various medications used for pain relief during labor. The students demonstrate understanding of the information when they identify which agent as the most commonly used opioid? A) Butorphanol B) Nalbuphine C) Fentanyl D) Meperidine

D. Meperidine

____ ____ allows the shoulders to rotate internally to fit the maternal pelvis

External rotation

A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. The nurse should assess for which of the following conditions associated with shoulder presentation during a vaginal birth?

Fetal anomalies

A nurse is completing the assessment of a woman admitted to the labor and birth suite.Which of the following would the nurse expect to include as part of the physical assessment? (Select all that apply.) A) Current pregnancy history B) Fundal height measurement C) Support system D) Estimated date of birth E) Membrane status F) Contraction pattern

Fundal height measurement Membrane status Contraction pattern As part of the admission physical assessment, the nurse would assess: - fundal height - membrane status and contractions * Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? A. Local infiltration B. Epidural block C. Regional anesthesia D. General anesthesia

General anesthesia is administered in emergency cesarean births

A nurse is caring for a pregnant client who is in labor. Which of the following maternal physiologic responses should the nurse monitor for in the client as the client progresses through childbirth? Select All

Increase in HR Increase in BP Increase RR

What are the phases of labor (in proper order)

Latent Phase Active Phase Transition Phase Pelvic Phase Perineal Phase Placental Separation Placental Expulsion

A client in her third trimester of pregnancy arrives at a health care facility complaining of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the RN indicates that the client has what?

Lightening

A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. the nurse understands that which of the following is causing extreme pain the client? Select all

Lower uterine segment distention Stretching and tearing of structures Dilation of cervix

What indicates placenta separation?

Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord.

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as?

Possible infection

A pregnant client is admitted to a maternity clinic after experiencing contractions. The nurse knows that which of the following marks the importance of the pauses between contractions during labor?

Restoration of blood flow to uterus and placenta

The ____ suture is located between the parietal bones and divides the skull into right and left halves

Sagittal

After teaching a group of students about fetal heart rate patterns, the instructor determines the need for additional teaching when the students identify which of the following as indicating normal fetal acid-base status? (Select all that apply.) A) Sinusoidal pattern B) Recurrent variable decelerations C) Fetal bradycardia D) Absence of late decelerations E) Moderate baseline variability

Sinusoidal pattern Recurrent variable decelerations Fetal bradycardia

Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy.

TRUE

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 delivered once and is pregnant a second time. What explanation should the nurse offer the client?

The cervix takes around 12-16 hours to dilate during first pregnancy

When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: A. 15 to 30 minutes B. 5 to 10 minutes C. 45 to 60 minutes D. 60 to 75 minutes

The correct response is A. The current recommendation is that intermittent FHR is assessed every 15 minutes during the active phase of labor.

How is fetal presenting part determined?

The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

The assessment of a pregnant client, who is toward the end of her third trimester, reveals that she has increased prostiglandin levels. Which of the following factors should the nurse assess for in the client? Select all that apply

a. reduction in cervical resistance b. Myometrial contraction d. Softening and thinning of the cervix

Contractions every 3 minutes with cervical dilation of 5 cm and contractions every 21/2 minutes with cervical dilation of 7 cm suggest the __________ phase of labor.

active

___________________ describes the irregular variations or absence of fetal heart rate (FHR) due to erroneous causes on the fetal monitor record.

artifact

An increase in prostiglandins leads to myometrial ______ and to a reduction in cervical resistance

contractions

The fetal head at the vaginal opening is termed _________ and occurs before birth of the head.

crowning

A nurse is caring for a client in labor who is delivering. Which of the following fetal responses should the nurse monitor for in the client's baby

decrease in circulation and perfusion to the fetus

____ is downward movement of the fetal head until it is within the pelvic inlet

descent

a nurse is caring for a pregnant client in labor in the health care facility. The nurse knows that which of the following marks the termination of the first stage of labor in the client

dilation of the cervix to 10cm

____occurs when the greatest transverse diameter of the head in vertex passes through the pelvic inlet

engagement

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs?

every 30 minutes

The head emerges through extension under the symphasis pubis, along with the shoulders

extension

If the nitrazine test is inconclusive, an additional test, called the ________________ test, can be used to confirm rupture of membranes

fern

_____ occurs as the vertex meets resistance from the cervix, walls of the pelvis, or pelvic floor

flexion

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? A) Frank B) Full C) Complete D) Footling

frank "I frankly dont care if I show my butt"

Vaginal birth is most favorable with ______ type of pelvis because the inlet is round and the outlet is roomy

gynecoid

- Green fluid may indicate that the fetus has passed meconium secondary to:

hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

Pelvic phase of the second stage of labor

is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.

Turning the woman on her left side would be an appropriate intervention for a _______ deceleration pattern.

late

Contractions every 5 minutes with cervical dilation of 3 cm is typical of the _______ phase.

latent

FHR is assessed every 30 to 60 minutes during the _________ phase of labor.

latent

_____ occurs when the fetal presenting part begins to descend into the maternal pelvis

lightening

client reports increased respiratory capacity, decreased dyspnea, increased pelvic pressure, cramping, and low back pain, more frequent urination. Also, edema in lower extremities (a result of blood stasis of blood pooling) and increased vaginal discharge. What should the nurse suspect?

lightening when fetal presenting part begins to descend into pelvis ( may occur two weeks before labor)

Of all of the synthetic opioids ___________ is the most commonly used opioid for the management of pain during labor.

meperidine

The elongated shape of the fetal skull at birth as a result of overlapping of the cranial bones is known as ______

molding

Respiratory depression Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of ____________

naloxone.

When the presenting part is above the ischial spines, it is noted as a ____________ station.

negative

A sudden increase in energy on the part of the expectant women 24-48 hours before the onset of labor is sometimes referred to as

nesting

The birth _____ is the route through which the fetus must travel to be birthed vaginally

passageway

The cervix, vagina, and pelvic floor muscles are the soft tissues of one of the 5 P's

passageway

Breech positions are associated with what factors?

prematurity, placenta previa, multiparity, abnormalities (fibroids), congenital anomalies such as hydrocephaly

Passage of the mucous plug

premonitory sign of labor