RN-45 Lippincott Quiz Chapter 13

The nurse is caring for a prenatal client in the clinic. The client states, "I wish I did not have to go through the pain of labor and a vaginal birth and could just schedule a cesarean birth instead." What is an appropriate response(s) by the nurse? Select all that apply.

"Newborns who are born vaginally have less suctioning after birth" "Newborns who are born following the laboring process have better respiratory adaptation"

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign?

"The presenting part is at the true pelvis and is engaged."

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic?

A cephalohematoma Rationale: Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?

Ask the woman to describe why she believes that she is in labor. Rationale: The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information.

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?

Crowning.

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?

Decrease in circulation and perfusion to the fetus. Rationale: When monitoring fetal responses in a client experiencing labor, the nurse should monitor for a decrease in circulation and perfusion to the fetus secondary to uterine contractions.

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

Fetal heart rate in relation to contractions. Rationale:

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

Fetal lie. Rationale: Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.

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

Have a blue bulb suction and an infant warmer ready. Rationale: 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.

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 BP, HR & RR Rationale: Monitor for an increase in the heart rate by 10 to 20 bpm, an increase in systolic blood pressure by as much as 35 mm Hg, and an increase in respiratory rate.

Uterine contractions are assessed according to frequency, duration, and ________________.

Intensity.

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 perpendicular to that of client. Rationale: If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position.

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?

Nothing. Normal time for stage three is 5-30mins. Rationale: Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.

In a cephalic presentation, the presenting part is usually the ___________ portion of the fetal head.

Occipital.

The passageway consists of the maternal __________ and soft tissues.

Pelvis.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?

Radiates from the back to the front. Rationale: Contractions that begin in the back and then radiate to the front are typical of true labor.

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 2030 related to women in labor?

Reduce the rate of cesarean births among low-risk women. Rationale: Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.

The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?

Second Rationale: The second stage of labor is between full dilation (dilatation) and birth of the infant. This woman has completed transition and is in the second stage of labor. The third stage begins with the birth of the baby and ends with delivery of the placenta. The active phase begins at 4 cm cervical dilation and ends when the cervix is dilated 8 cm.

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions. Rationale: The nurse identifies a priority during the active and transitional stage of labor as working with the contractions to give birth. Being tense works against cervical dilation (dilatation) and fetal descent. For that reason, the client is encouraged to practice breathing techniques.

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?

Third.

The two primary types of fetal lie are longitudinal and _________________.

Transverse.

Braxton Hicks contractions diminish with walking or changing position.

True.

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

Allowing the woman time to be alone. Rationale: Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope.

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.

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 Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position.

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2 Rationale: 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.

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

At the time of placental delivery.

The fetal head is the largest and least compressible fetal structure.

True.

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

False.

The ratio of estrogen and progesterone remains constant throughout pregnancy into labor.

False.

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

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

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

ROA Rationale: R (right) O (occiput) A (anterior)

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

Fetal position Rationale: When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference.

During a spontaneous vaginal birth several things need to occur to the fetus in sequence. As the fetus encounters resistance, what is its usual reaction?

Flexion.

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:

Frequency.

When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche?

"You had a successful labor and vaginal delivery with your first pregnancy." Rationale: Reminding the client of her successful labor and birth best provides confidence, which strengthens a woman's psyche.

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?

Restoration of blood flow to the uterus & placenta. Rationale: The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta.

The nurse is working triage in the emergency department. The nurse realizes the client is in true labor when she states that the she is experiencing:

Ruptured membranes. Rationale: The nurse realizes that the client is in true labor when her membranes spontaneously rupture. At this point, the woman is transferred to the labor and delivery unit. Fetal engagement and expelling the mucus plug may occur a week before true labor begins. Contractions may or may not indicate true labor.

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate?

Administer the medication piggybacked into a primary IV line using a pump. Rationale: Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity. It is not given orally, via IM injection, or through a central venous access device.

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?

"I feel pressure in my vagina when I have the contraction" Rationale: True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt.

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

Cervix. Rationale: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

When the presenting part of the fetus reaches 0 station, _________ has occurred.

Engagement.

An anthropoid pelvis is most favorable for a vaginal birth.

False.

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:

Occuring about every 5 minutes. Rationale: if contractions last longer than 30 seconds and occur more often than 4 to 6 times per hour, the nurse should have the woman evaluated, especially if she is less than 38 weeks' pregnant.

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

Hemorrhage Rationale: During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments.

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?

The fetus is in the true pelvis and engaged. Rationale: When the fetus is at a 0 (zero) station, it is at the level of the ischial spines and said to be engaged.

A primigravida 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?

"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks" Rationale: The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care?

A woman may spend time thinking about what is happening to her.

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

Effacement Rationale: Effacement involves softening, thinning, and shortening of the cervical canal. Dilation (dilatation) refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

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 frequency of the contractions is every 5 mins. Rationale: Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider.

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 do not last long enough to be true labor. - Braxton Hicks contractions usually decrease in intensity with walking. - Braxton Hicks contractions get closer together with activity.

Braxton Hicks contractions usually decrease in intensity with walking. Rationale: 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 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?

Increase even if relaxing & taking a shower. Rationale: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency.

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?

Increased risk of infection. Rationale: After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse.

A client comes to the emergency department reporting strong contractions that have lasted for the past 2 hours. Which assessment will indicate to the nurse that the client is in true labor?

Progressive cervical dilation and effacement.

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?

Push with contractions and rest between them. Rationale: Make sure the woman pushes w/ contractions & rests between them. Holding the breath during contractions could cause a Valsalva maneuver or temporarily impede blood return to her heart due to increased intrathoracic pressure. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor.