Ch 13. Labor and Birth Process

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? Continue to monitor the progress of labor. Auscultate fetal heart rate (FHR) in the left upper quadrant. Prepare the client for cesarean birth of the fetus. Educate the client this fetal position may result in a longer labor.

Continue to monitor the progress of labor. Explanation: ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part. This is a common and favorable position for vaginal birth. Based on the ROA location, the nurse will auscultate FHR at the right lower quadrant of the client's abdomen (FHR will be loudest where the fetus' back is located). Occiput posterior (not anterior) positions are associated with longer, more difficult births.

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location? between the umbilicus and symphysis pubis at the level of the umbilicus one fingerbreadth below the umbilicus 2 cm above the umbilicus

at the level of the umbilicus Explanation: After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts approximately 1 cm (or fingerbreadth) each day after birth.

The nursing instructor is teaching a session on the birth process. During which stage does the woman's cardiac output increase 80% above the pre-labor level? first stage pushing immediately after birth transition stage

immediately after birth Explanation: Due to an increased demand for oxygen the cardiac output increases up to 80% immediately after birth. During the first stage of labor there is a moderate increase in the demand for oxygen. While pushing, cardiac output can increase by 40% to 50%. During transition, changes are more psychological than physiologic.

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

significant head molding Explanation: 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.

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." "This is not normal unless you are in active labor; come to the hospital and be checked." "That is something we expect with a second or third baby, but because it is your first, you need to be checked." "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."

"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." Explanation: 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 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? "This is just a way of determining your progress in labor." "This indicates that you start labor within the next 24 hours." "This means +1 and the baby is entering the true pelvis." "The presenting part is at the true pelvis and is engaged."

"The presenting part is at the true pelvis and is engaged." Explanation: 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? 0 to 2 5 to 7 3 to 4 8 to 10

8 to 10 Explanation: The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation (dilatation) would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

Which cardinal movement of delivery is the nurse correct to document by station? Descent Flexion Extension Internal rotation

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.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? diffuse abdominal cramping rupturing of fetal membranes start of regular contractions dilation (dilatation) of cervix diameter to 10 cm

dilation (dilatation) of cervix diameter to 10 cm Explanation: The first stage of labor terminates with the dilation (dilatation) of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occur during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.

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 client is in active labor. The duration of the contractions is every 5 minutes. The frequency of the contractions is every 5 minutes. The client can be sent home.

The frequency of the contractions is every 5 minutes. Explanation: 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. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.

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? promoting the woman's feelings of control providing clear information about procedures allowing the woman time to be alone encouraging the woman to use relaxation techniques

allowing the woman time to be alone Explanation: Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.

Which client outcome during active and transitional labor is best? The client will state a pain level of 7 and under during contractions. The client will practice breathing techniques during contractions. The client will walk in the hall for 15 minutes every 2 hours. The client will tolerate 8 oz (240 ml) of clear liquids during labor process.

The client will practice breathing techniques during contractions. Explanation: 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. It may be unrealistic to state that the pain level is under 7 in the active and transitional phases. Walking in the hall and tolerating liquids also depends on the client.

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? crowning effacement dilation (dilatation) molding

effacement Explanation: The nurse is explaining about effacement, which 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 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 slight decrease in body temperature increase in gastric emptying and pH

increase in heart rate increase in blood pressure increase in respiratory rate Explanation: 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.

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 potential rapid birth of fetus potential placenta previa increased risk of breech presentation

increased risk of infection Explanation: 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. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

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." "I will have a strong one and then the next one will be weaker." "I feel the tightening primarily in the front of my belly." "The contractions lessen after I drink a large glass of water."

"I feel pressure in my vagina when I have the contraction." Explanation: 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.

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

-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.

Which cardinal movement allows the fetus to travel through the birth canal most efficiently? Extension External rotation Flexion Engagement

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 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 at 60° to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is at 45° to that of client.

Long axis of fetus is perpendicular to that of client. Explanation: 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. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.

A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. What report by the client would lead the nurse to predict the woman is close to labor? nesting dilation (dilatation) effacement ripening of the cervix

nesting Explanation: Nesting is the activity or burst of energy women often experience prior to the onset of labor. The client could express feeling energetic or through a report of her activities at home. Dilation (dilatation), effacement, and cervical ripening are all observed by the provider during assessment.

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? cephalic vertex breech shoulder

shoulder Explanation: The three main fetal presentations are cephalic or vertex, with the head as the presenting part, breech, with the pelvis as the presenting part, and shoulder, with the scapula as the presenting part.