Ch. 13 Labor and birth process coursepoint

Assessment reveals that a woman's cervix is approximately 1 cm in length. The nurse would document this as:

50% effaced A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 1/2 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.

The laboring patient is having contractions every 2-3 minutes, lasting 45-60 seconds and of strong intensity. The fetal head crowns when the client pushes. The cervix is completely dilated (10 centimeters) and 100 percent effaced. The nurse assesses the patient to be in what stage or phase of labor?

Second The second stage of labor is between full dilatation and delivery 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.

A nurse is teaching a group of nursing students about the role of progesterone in labor. Which of the following should the nurse explain as the function of progesterone?

Suppresses the uterine irritability throughout pregnancy The function of progesterone is to suppress uterine irritability throughout pregnancy. The function of estrogen is to promote oxytocin production and to sensitize the uterus to the effects of oxytocin. Prostaglandin, and not progesterone, stimulates the smooth muscle contractions in the uterus.

A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess?

Fetal anomalies The nurse, along with the physician, has to assess for fetal anomalies, which are usually associated with a shoulder presentation during a vaginal birth. The other conditions include placenta previa and multiple gestations. Uterine abnormalities, congenital anomalies, and prematurity are conditions associated with a breech presentation of the fetus during a vaginal birth.

The assessment of a pregnant client, who is toward the end of her third trimester, reveals that she has increased prostaglandin levels. Fore which factors should the nurse assess the client?

• Softening and thinning of the cervix • Reduction in cervical resistance • Myometrial contractions Upon seeing the increased prostaglandin levels, the nurse should assess for myometrial contractions, leading to a reduction in cervical resistance and subsequent softening and thinning of the cervix. The uterus of the client will appear boggy during the fourth stage of delivery, after the completion of pregnancy and birth. Hypotonic character of the bladder is also marked during the fourth stage of pregnancy, not when the prostaglandin levels rise, marking the onset of labor.

A client is in the transitional phase of labor. Which of the following would the nurse most likely find?

• Strong desire to push • Irritability with restlessness A strong desire to push occurs most often in the transitional phase of the first stage of labor. During this phase the woman commonly experiences increased apprehension and irritability with restless movements and feelings of loss of control and being overwhelmed. Cervical dilation from 4 to 7 cm characterizes the active phase of the first stage of labor. Contractions occurring every 2 to 5 minutes are associated with the active phase of the first stage of labor. The woman in the early or latent phase of the first stage of labor often is filled with apprehension but is excited about the start of labor. During the active phase of the first stage of labor, cervical effacement of 40% to 80% occurs.

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most?

Positive reinforcement Any women, even ones who have had natural childbirth classes, have a difficult time maintaining positive coping strategies during this phase of labor. Many women describe feeling out of control during this phase of labor. A woman in transition needs support, encouragement, and positive reinforcement. (

A nurse is caring for a client in her fourth stage of labor. Which of the following assessments would indicate normal physiologic changes occurring during the fourth stage of labor?

• Well-contracted uterus in the midline • Mild uterine cramping and shivering • Decreased intra-abdominal pressure The normal physiologic changes for which a nurse should assess during the fourth stage of labor are a well-contracted uterus in the midline of the abdomen, mild cramping pain and generalized shivering, and decreased intra-abdominal pressure. Hemodynamic changes are due to normal blood loss during delivery, causing moderate tachycardia and a slight fall in the blood pressure during the fourth stage of labor. A fall in the pulse rate and increased blood pressure are not normal findings occurring during the fourth stage of labor.