OB 15
The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? (Select all that apply.) A) False labor contractions are irregular. B) True labor contractions disappear when asleep. C) False labor contractions lead to cervical dilation. D) True labor contractions occur in the abdomen and groin. E) False labor contractions do not increase in duration, frequency, and intensity.
A) False labor contractions are irregular. E) False labor contractions do not increase in duration, frequency, and intensity. False labor contractions are irregular. True labor contractions increase in duration, frequency, and intensity. False labor contractions disappear when asleep and occur in the abdomen and groin. True labor contractions lead to cervical dilation.
The fetus of a patient in labor is in a vertex presentation and at a -1 station. How should the nurse interpret the location of the fetal head? A) Floating B) Engaged C) Crowning D) At the ischial spines
A) Floating Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. The degree of engagement is established by vaginal and cervical examination. Station refers to the relationship of the presenting part of the fetus to the level of the ischial spines. If the presenting part is above the spines, the distance is measured and described as minus stations, such as -1. The fetal head is currently floating. The head would be engaged if it were at the level of the ischial spines. Crowning is when the top of the fetal head is visible and birth is imminent.
When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture? A) Meconium-stained amniotic fluid B) Fetus presenting in an LOA position C) Maternal pulse of 90 to 95 beats/min D) Blood-tinged vaginal discharge at full dilation
A) Meconium-stained amniotic fluid Meconium staining means that the fetus has lost rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. The fetal presentation is not assessed during membrane rupture. The maternal pulse rate of 90 to 95 beats/min is expected during labor. Blood-tinged vaginal discharge at full dilation is an expected finding.
The nurse providing care to patients in the labor and delivery suite desires to support the 2020 National Health Goals to reduce maternal and infant mortality after labor and birth. Which action should the nurse perform to support these goals? A) Support laboring patients through the use of controlled breathing techniques. B) Encourage laboring patients to use analgesia to control painful contractions. C) Recommend the use of epidural and spinal anesthesia to aid in the labor process. D) Apply specific infection control practices during the labor and birthing processes.
A) Support laboring patients through the use of controlled breathing techniques. Nurses can help the nation achieve the 2020 National Health Goals for reducing maternal and infant mortality after labor and birth by teaching patients as much as possible about labor, so they are able to use as little analgesia and anesthesia as possible. The less anesthesia and analgesia used, the fewer the complications, which can result in fetal or maternal death. One approach would be to support laboring patients through the use of controlled breathing techniques. Infection control practices are not identified as strategies to reduce maternal and infant mortality after labor and birth.
The nurse is teaching a pregnant patient the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor? A) The fetal head bends forward onto the chest. B) The fetal head rotates into a transverse position. C) The head extends so that the face and chin are born. D) The shoulders move into an anteroposterior position.
A) The fetal head bends forward onto the chest. The cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation, and expulsion. In descent, the fetal head bends forward onto the chest once the head presses on the sacral nerves at the pelvic floor. The fetal head rotates into a transverse position prior to expulsion. The head extends so that the face and chin are born during extension. The shoulders move into an anteroposterior position during external rotation.
During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs? A) Turn the patient onto the left side. B) Assess fetal heart rate for fetal safety. C) Test a sample of amniotic fluid for protein. D) Instruct to bear down with the next contraction.
B) Assess fetal heart rate for fetal safety. If membranes rupture during labor, the fetal heart rate should be assessed immediately to be certain that the umbilical cord hasn't prolapsed and is now being compressed against the cervix by the fetal head. The patient does not need to be turned onto the left side. The amniotic fluid is tested for pH and not protein. Bearing down at this time could be dangerous, considering there is no way of knowing how much the cervix has dilated at the time of membrane rupture.
After assessment, the nurse determines that a pregnant patient's fetus has a face presentation that is pointing to the patient's left side with transverse pointing. How should the nurse document this assessment finding? A) LCT B) LMT C) LOT D) ROA
B) LMT Fetal position is the relationship of the presenting part to a specific quadrant and side of the patient's pelvis. The maternal pelvis is divided into four quadrants according to the mother's right and left. Four parts of a fetus are landmarks to describe the relationship of the presenting part to one of the pelvic quadrants that include the occiput (O), the chin (mentum [M]), the sacrum (Sa), or the acromion process (A). Position is indicated by an abbreviation of three letters. The first letter defines whether the landmark is pointing to the patient's right (R) or left (L).The middle letter denotes the fetal landmark. The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T). The nurse should document LMT. The other choices are incorrect interpretation of the findings and use of the abbreviations.
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? A) Powers B) Passage C) Passenger D) Psychological outlook
B) Passage Passage focuses on the size and contour of the pregnant patient's pelvis. Passenger addresses the size, position, and presentation of the fetus. Powers determine if uterine factors for labor are adequate. Psychological outlook focuses on the pregnant patient's ability to view labor as a positive experience.
While conducting Leopold maneuvers, the nurse determines that the fourth maneuver does not need to be done. What information caused the nurse to make this decision? A) The fetus is in a cephalic presentation. B) The fetus is not in a cephalic presentation. C) The nurse palpated angular bumps and nodules. D) The nurse palpated a round and hard mass that moves freely.
B) The fetus is not in a cephalic presentation. The fourth Leopold maneuver is only done if the fetus is in a cephalic presentation because it determines fetal attitude and degree of fetal extension into the pelvis. Angular bumps and nodules indicate the fetal knees, elbows, hands, and fingers. A round hard mass that moves freely is the fetal head.
After delivery of the placenta, a patient's uterus is sluggish to contract. What should the nurse prepare to do to assist the patient at this time? A) Administer intravenous fluids. B) Measure blood pressure every 15 minutes. C) Administer oxytocin (Pitocin) as prescribed. D) Prepare to administer blood products as prescribed.
C) Administer oxytocin (Pitocin) as prescribed. After placenta inspection, if the patient's uterus has not contracted firmly on its own, the primary care provider may prescribe oxytocin (Pitocin) to help uterine contraction. Intravenous fluids and blood pressure measurement will not encourage uterine contract. It is premature to anticipate the patient needing a blood transfusion at this time.
During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time? A) Risk for fluid volume deficit B) Anxiety related to stress of labor C) Risk for ineffective breathing pattern related to breathing exercises D) Powerlessness related to duration of labor
C) Risk for ineffective breathing pattern related to breathing exercises Hyperventilation occurs when the patient exhales more deeply than inhaling. As a result, extra carbon dioxide is blown off, and respiratory alkalosis results. This can occur during actual labor. The best way to manage hyperventilation is to prevent it by coaching the patient to end all breathing sessions with a long cleansing breath to help restore carbon dioxide balance. Difficulty using breathing techniques will not cause a risk for fluid volume deficit, anxiety related to stress of labor, or powerlessness related to duration of labor.
During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding? A) Variable decelerations that are too unpredictable to count B) Fetal baseline rate increasing at least 5 mmHg with contractions C) A shallow deceleration occurring with the beginning of contractions D) Fetal heart rate declining late with contractions and remaining depressed
D) Fetal heart rate declining late with contractions and remaining depressed Late decelerations are those that are delayed until 30 to 40 seconds after the onset of a contraction and continue beyond the end of a contraction. This is an ominous pattern in labor because it suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during uterine contractions. With uteroplacental insufficiency, the nurse will not observe on the monitor tracing variable unpredictable decelerations, an increase in fetal heart rate with contractions, or shallow decelerations at the beginning of contractions.
The nurse is determining care for a patient entering the active phase of labor. Which outcome would be the most appropriate for the patient at this time? A) Patient will develop an irresistible urge to push. B) Patient will combat feelings of nausea to prevent vomiting. C) Patient will remain in the supine position during contractions. D) Patient will adjust body to attain the most comfortable position.
D) Patient will adjust body to attain the most comfortable position. During the active phase of labor, contractions grow so much stronger and last so much longer than they did in the latent phase. An appropriate outcome at this time would be that the patient keeps active and assumes whatever position is most comfortable during this time, except flat on the back or supine. An irresistible urge to push and nausea and vomiting may occur during the transition phase of labor.
The nurse is concerned that a patient in the second stage of labor will experience a drop in blood pressure. What should the nurse do to prevent this from occurring? A) Position the patient supine. B) Encourage oral fluid intake. C) Administer intravenous fluids. D) Position the patient side-lying.
D) Position the patient side-lying. If a patient lies in a supine position and pushes during the second stage of labor, pressure of the uterus on the vena cava causes the blood pressure to drop, leading to hypotension. A side-lying position during the second stage of labor can help avoid such a problem. Fluids would be indicated if the patient is having epidural anesthesia.
A pregnant patient in labor is being encouraged to push with contractions. In which position should the nurse assist to help the patient at this time? A) Squatting while holding the breath B) Lying on side, arms grasped on abdomen C) Lying supine with legs in lithotomy stirrups D) Semi-Fowler's position with legs bent against the abdomen.
D) Semi-Fowler's position with legs bent against the abdomen. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen. Lying on the side or supine in the lithotomy position are not positions conducive to successful delivery. The patient should be coached to not hold the breath during a contraction or pushing because this could increase intrathoracic pressure, which could interfere with blood supply to the uterus.
The nurse is preparing to assess the frequency of contractions for a patient in labor. Which process should the nurse use to time the contractions? A) Number of contractions that occur in 5 minutes B) The end of one contraction to the beginning of the next C) The interval between the acmes of two consecutive contractions D) The interval between the beginning and the end of one contraction
D) The interval between the beginning and the end of one contraction To determine the beginning of a contraction without a monitor, rest a hand on a woman's abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. Contractions are not timed by measuring the number of contractions in 5 minutes, the end of one contraction to the beginning of the next, or by using the interval between the acmes of two consecutive contractions.
