Prep-U Ch. 8: The Labor Process

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? A. The client's cervix is fully dilated. B. The infant is born. C. The client has contractions once every two minutes. D. The client experiences her first full contraction.

A. The client's cervix is fully dilated. * The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.

The nurse has provided care to a client throughout labor and delivery and is comparing assessment findings with expected norms. When tracking the client's cardiac assessments, the nurse should predict that cardiac output will likely be the highest at which time? A. During active labor B. Second stage of labor C. Immediately after birth D. During transition

C. Immediately after birth * There is a moderate increase in cardiac output throughout the first stage of labor. During pushing (second stage), cardiac output may be increased as much as 40 percent to 50 percent above the pre-labor level. Immediately after birth, it may peak at 80 percent above the pre-labor level.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A. shoulders B. occiput C. brow D. buttocks

B. occiput * With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

Which nursing action would the nurse anticipate doing more often for a cesarean birth newborn than a vaginal birth newborn? A. Monitor the temperature. B. Assess voiding. C. Note the number of stools. D. Suction the upper airway.

D. Suction the upper airway. * The neonate born via cesarean birth will need more upper airway suctioning as the newborn did not have the maternal contractions squeeze the fluid from the lung fields. There is no change is assessing temperature, voiding, and the number of stools.

Which nursing action is a priority when the fetus is at the +4 station? A. Have a blue bulb suction and an infant warmer ready. B. Have a tocometer and a client gown ready. C. Provide lubricating jelly and an internal monitor. D. Prepare for an immediate cesarean birth.

A. Have a blue bulb suction and an infant warmer ready. * At +4 station, the fetus is being born. The priority nursing action is to have a blue bulb or suction device for airway clearance and an infant warmer ready. During admission, the nurse will place a tocometer on the maternal stomach and have a gown ready. For checking effacement and dilation (dilatation), the nurse will have a lubricant and possibly an internal monitor per health care provider orders. A cesarean birth is not needed as the fetus has progressed through the birth canal.

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? A. The client is fully effaced. B. The fetus is floating high in the pelvis. C. The fetus is in the true pelvis and engaged. D. The fetus has descended down the birth canal.

C. The fetus is in the true pelvis and engaged. * When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged. Determining the station does not mean that the client's cervix is fully effaced. If the fetus is floating high in the pelvis, its station is noted as a negative number. Descending into the pelvis or birth canal is documented as a positive number.

During the second stage of labor, a woman is generally: A. very aware of activities immediately around her. B. anxious to have people around her. C. no longer in need of a support person. D. turning inward to concentrate on body sensations.

D. turning inward to concentrate on body sensations. * Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? A. +4 B. +2 C. 0 D. -2

D. -2 * When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A fetus at 0 (zero) station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. uterus becomes globular B. fetal head at vaginal opening C. umbilical cord shortens D. mucous plug is expelled

A. uterus becomes globular * 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. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of 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? A. Radiates from the back to the front B. Slows when the woman changes position C. Occurs in an irregular pattern D. Lasts about 20 to 25 seconds

A. Radiates from the back to the front * Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document? A. completion of the fourth stage of labor B. attachment phase C. completion of the third stage of labor D. transition phase

C. completion of the third stage of labor * The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The fourth stage begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1 to 4 hours after birth). Within this fourth stage, the attachment process begins with the mother inspecting the newborn and desiring to cuddle and breastfeed the newborn.

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? A. head flexed forward so much that the chin touches the sternum B. chin in moderately flexed military position C. fetus in partial extension with brow presenting to birth canal D. fetus in complete extension with back arched

A. head flexed forward so much that the chin touches the sternum * A fetus in good attitude is in complete flexion; the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. This usual "fetal position" is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible. The other attitudes listed are not ideal, because larger diameters of the fetus' skull are presenting.A fetus in good attitude is in complete flexion; the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs. This usual "fetal position" is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible. The other attitudes listed are not ideal, because larger diameters of the fetus' skull are presenting.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? A. "I feel pressure in my vagina when I have the contraction." B. "I will have a strong one and then the next one will be weaker." C. "I feel the tightening primarily in the front of my belly." D. "The contractions lessen after I drink a large glass of water."

A. "I feel pressure in my vagina when I have the contraction." * True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? A. Fetal heart rate in relation to contractions B. The station in which the fetus is located C. Maternal heart rate and blood pressure D. Maternal request for pain medication

A. Fetal heart rate in relation to contractions * The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.

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? A. Molding B. Caput succedaneum C. Cephalohematoma D. Vertex presentation

A. Molding * The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.

The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? A. The cervix is softening B. The uterus is relaxing C. The cervix is dilating D. The perineum is relaxing

A. The cervix is softening * The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.

Which change in client status suggests that labor is anticipated? A. The woman can breathe easier throughout the day. B. The woman does not have to urinate as often. C. Uterine contractions occur but diminish when resting. D. The woman is anxious about the birth process.

A. The woman can breathe easier throughout the day. * Symptoms that the woman is able to breathe easier strongly suggest lightening. Lightening means that the fetus has dropped into the pelvis or is engaged. Typically when the fetus is in the pelvis, it impinges on the bladder causing the need for more frequent urination. Braxton Hicks contractions are the first contractions that may be present for some time. These contractions occur but can diminish when walking or when the woman's position changes. Anxiety and anticipation are commonly felt throughout pregnancy.

The nurse is caring for a client in active labor. Which assessment finding requires health care provider notification? A. gross proteinuria B. hyperventilation C. elevated WBC count D. nausea

A. gross proteinuria * There are normal physiologic changes that occur during the labor process. Gross proteinuria is not anticipated and is a sign of a complication. The health care provider is notified. If hyperventilation occurs, the woman is encouraged to breathe into her cupped hands or a paper bag. An elevated white blood cell count is common due to the immune response. Nausea is common due to prolonged gastric emptying.

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? A. is narrow transversely B. is ideal for birth C. has weaker bones than normal D. is "male" shaped

A. is narrow transversely * A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis.

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. pelvic phase of the second stage. D. early phase of the third stage.

A. latent phase of the first stage. * 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 active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs 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. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.

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? A. Braxton Hicks contractions get closer together with activity. B. Braxton Hicks contractions usually decrease in intensity with walking. C. Braxton Hicks contractions do not last long enough to be true labor. D. Braxton Hicks contractions cause "ripening" of the cervix.

B. Braxton Hicks contractions usually decrease in intensity with walking. * Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? A. Admission time and time of fetal birth B. Complete cervical dilation (dilatation) and time of fetal birth C. Effacement time and time when contractions are regular D. Time of mucus plug expulsion and full cervical dilation

B. Complete cervical dilation (dilatation) and time of fetal birth * The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.

A nurse is conducting a continuing education program for a group of nurses working in the perinatal unit. After reviewing information about the maternal bony pelvis with the group, the nurse determines that the teaching was successful based on which statement by the group? 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 pelvic outlet is associated with the true pelvis. * 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 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.

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? 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 contractions every 4 minutes, lasting about 1 minute * 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, and pink-tinged secretions with irregular contractions suggest false labor.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A. -2 B. -1 C. 0 D. +1

C. 0 * Fetal engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.

Which nursing action has a negative effect on fetal descent? A. laying the client on the left side B. using a tap water enema C. administering opioid pain medication D. walking the client in the hall

C. administering opioid pain medication * Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process. The opioid effect can provide the mother with a needed break and allow her to rest between contractions. The mother may lie in any position comfortable. Neither eliminating stool nor walking in the hall will slow fetal transport.

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: A. internal rotation, descent, extension, flexion, external rotation, expulsion B. descent, flexion, external rotation, extension, internal rotation, expulsion C. descent, flexion, internal rotation, extension, external rotation, expulsion D. internal rotation, flexion, descent, extension, external rotation, expulsion

C. descent, flexion, internal rotation, extension, external rotation, expulsion * The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.

When educating a group of nursing students about the different types of pelves, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type? A. gynecoid B. anthropoid C. platypelloid D. android

C. platypelloid * A platypelloid pelvis is a flat pelvis with a wider transverse diameter than anterior-posterior diameter, ischial spines are wide apart, and the sacrum is short. In a gynecoid pelvis, the inlet is oval, the pubic arch is wide, it has dull ischial spines, and the sacrum has no anterior or posterior inclinations. In an android pelvis, the inlet is heart shaped, the ischial spines are prominent, and the sacrum is straight. In an anthropoid pelvis, the anterior-posterior diameter is longer than the transverse diameter, the ischial spine is somewhat prominent, and the sacrum is inclined posteriorly.

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother? A. thick vernix B. single palmar crease C. significant head molding D. absence of testicular rugae

C. significant head molding * Since this is the mother's first birth, the birth canal has never been stretched. The labor process may take longer and may be tighter leading to significant molding as the fetal body, particularly the head, molds to the mother's birth canal. Thick vernix and absence of testicular rugae are a characteristics of prematurity. Genetic conditions such as trisomy 13 have characteristics of a single palmar crease as one of the signs of the potential disorder.

During a visit to the prenatal clinic, a pregnant woman asks the nurse, "What causes labor to start?" Which response by the nurse would be appropriate? A. "Labor starts when the fetus moves into the pelvis." B. "Just before labor, the level of the hormone oxytocin drops." C. "Labor starts when the uterus can't grow any further." D. "Labor starts from a combination of several maternal and fetal hormones working together."

D. "Labor starts from a combination of several maternal and fetal hormones working together." * There are several hypotheses regarding what causes labor to begin. A single causative factor of labor has not yet been determined. Studies indicate labor onset results from a combination of several maternal and fetal hormones working together. Fetal movement and uterine size are not associated with the onset of labor. A rise in oxytocin has been suggested as playing a role.

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? A. -5 B. 0 C. +1 D. +4

D. +4 * As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? A. Fetal presentation B. Fetal attitude C. Fetal position D. Fetal lie

D. Fetal lie * Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.

The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with: A. the passenger. B. the passageway. C. the psyche. D. the powers.

D. the powers. * One of the four "P's" is the power of the uterine contractions. This power begins with regular contractions which become closer together and increase in intensity. The powers push the fetus down the birth canal.