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The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long the client will be in labor?

"Your partner is in active labor; they are progressing at this point and we will keep you posted." Explanation: At 7 cm dilated, the client is considered in the active phase of labor. There is no science that can predict the length of labor. The client is progressing in labor, and it is best that the nurse not give the family a specific time frame.

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

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

It helps to rotate the fetus in a posterior position. Explanation: The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.

Which client outcome during the active phase labor is best?

The client will practice breathing techniques during contractions. Explanation: The nurse identifies a priority during the active phase 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. It may be unrealistic to state that the pain level will be less than 7 in the active phase. Walking in the hall and tolerating liquids also depends on the client.

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 Explanation: Stage three begins with the birth of the baby and ends with delivery of the placenta.

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

At the time of placental delivery Explanation: The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth. Neither the time when the woman begins to push nor when she is moved to the postpartum unit are notable.

Which cardinal movement allows the fetus to travel through the birth canal most efficiently?

Flexion Explanation: As the fetus progresses down the birth canal, flexion coaxes the fetus to assume the position of the smallest diameter of the fetal head to fit through the dimension of the pelvis. Extension and external rotation occur later in the labor process before birth and passes the fetal head through the pubic arch to birth of the head. Engagement occurs when the fetal head descends to the level of the ischial spines and can occur 2 weeks prior to the initiation of labor.

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:

occurring about every 5 minutes. Explanation: The nurse needs to determine if the client is experiencing true labor contractions. True labor contractions are commonly felt in the lower back, in contrast to Braxton Hicks contractions that typically last about 30 seconds and occur primarily in the abdomen and groin and are relieved by walking, voiding, eating, increasing fluid intake, or changing positions. However, 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.

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

These contractions help in softening and ripening the cervix. Explanation: Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.

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

-2 Explanation: 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.

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

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

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. Explanation: 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.

Which cardinal movement of delivery is the nurse correct to document by station?

Descent Explanation: Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.

During a prepared childbirth class, the nursing is discussing the differences between true and false labor. Which responses by a client indicate an understanding of false labor? Select all that apply.

>...... "Walking will make my labor pains increase if I am experiencing false labor." X...... "False labor pains begin in the back and move downward toward the pelvis. >...... "Maintaining hydration by drinking water will lessen false labor pains." X...... "Vaginal pressure may intensify during false labor." X...... "The intensity of contractions is inconsistent in false labor." False labor is a phenomena that occurs in the later weeks of pregnancy. During false labor, the woman may experience contractions. These contractions may vary in intensity. They do not become regular nor do they increase in intensity. Activity such as walking can increase contraction strength and frequency during true labor, but walking does not increase the manifestations of false labor. Remaining hydrated is important. Dehydration may result in uterine irritability and false labor pains. False labor pains are felt in the abdomen; in contrast, true labor contractions begin in the back and radiate to the front of the abdomen. Pelvic pressure increases during true labor

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation (dilatation) to occur?

cervical ripening and softening Explanation: The ripening and softening of the cervix that result from the effects of prostaglandins and pressure from Braxton Hicks contractions are essential for effacement and dilation (dilatation) of the cervix. Lightening occurs when the fetal presenting part begins to descend into the true pelvis. Bloody show occurs as the mucus plug is expelled as a result of cervical softening and increased pressure of the presenting part.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput Explanation: 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.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

>....... increase in heart rate >....... increase in blood pressure >....... increase in respiratory rate X....... slight decrease in body temperature X....... increase in gastric emptying and pH When caring for a client in labor, the nurse should 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. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?

Longitudinal Explanation: The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie. In the transverse lie, the fetus lies crosswise to the maternal spine. An oblique lie is between the two. There is not an obtuse lie.

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate?

"You need the cervix to thin so it can stretch more easily." Explanation: The rigid cervix of pregnancy must become distensible to expel the fetus. Before labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur. These changes can occur 1 month to 1 hour before actual labor begins. As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix. These changes occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions. Cervical thinning has no effect on contractions or fetal positioning. It is not a sign of true labor.

A nurse is monitoring a client in labor. Which assessment finding is most concerning to the nurse?

Although slight temperature elevations are normal during labor, a temperature of 101.6°F (38.7°C) indicates an infection and should be reported to the health care provider. As the client progresses through birth, numerous physiologic responses occur that assist the client to adapt to the laboring process. Some of these changes include heart rate increasing by 10 to 20 beats/min; blood pressure increases by up to 35 mm Hg; and respiratory rate increases as more oxygen is consumed. Nausea and vomiting are common during labor, especially during the active phase, due to decreased gastric motility.