Ch 15: Nursing Care of a Family During Labor and Birth
d) Blue Pg. 350-352 Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.
17. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: a) Olive green b) Yellow c) Pink d) Blue
c) Fetal lie Pg. 331 Fetal lie describes the position of the long axis of the fetus in relation to the long axis of the pregnant woman.
31. What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? a) Fetal attitude b) Fetal position c) Fetal lie d) Fetal presentation
c) 0 Pg. 334-335 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.
46. Assessment of a client 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
d) 110 to 160 bpm Pg. 357 The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.
19. The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? a) 100 to 150 bpm b) 90 to 140 bpm c) 120 to 170 bpm d) 110 to 160 bpm
c) Fetal position Pg. 332-334 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. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
2. 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? a) Fetal station b) Fetal size c) Fetal position d) Fetal attitude
a) The fetus is in the true pelvis and engaged Pg. 334-335 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.
29. 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 fetus is in the true pelvis and engaged b) The client is fully effaced c) The fetus is floating high in the pelvis d) The fetus has descended down the birth canal
c) Effacement Pg. 340 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.
30. 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? a) Dilation (dilatation) b) Molding c) Effacement d) Crowning
b) Take no extra measures; prepare for a standard labor Pg. 347-348 The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid inlet allows the fetus room to pass through the dimensions of the bony passageway. Therefore, the nurse does not need to take any extra measures nor is there a reason to expect that labor will take a long time. Anticipating the client will need one-to-one nursing and preparing for vital signs and fetal monitoring hourly is not indicated. These measures can be instituted should an issue arise.
4. The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? a) Notify the client's support person that the labor is typically long b) Take no extra measures; prepare for a standard labor c) Anticipate this client is a one-to-one registered nursing assignment d) Prepare for vital signs and fetal monitoring hourly
c) Central nervous system (CNS) Pg. 357 The nurse should identify that the decreased variability is associated with the fetal central nervous system (sympathetic and parasympathetic). Baseline variability is the beat-to-beat variations in the fetal heart rate (FHR), which is a normal FHR finding. Decreased beat-to-beat variability indicates CNS involvement. Other systems, such as gastrointestinal, genitourinary, and musculoskeletal, are not associated with decreased beat-to-beat variability in the FHR.
12. A nurse notes the digital readings of the electronic fetal monitor show decreased beat-to-beat variability in a client who was just admitted to the unit. The nurse interprets this as indicating which system is mainly being affected in the fetus? a) Genitourinary system b) Musculoskeletal system c) Central nervous system (CNS) d) Gastrointestinal system
c) Radiates from the back to the front Pg. 336 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.
13. 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) Slows when the woman changes position b) Lasts about 20 to 25 seconds c) Radiates from the back to the front d) Occurs in an irregular pattern
b) Withdrawal of progesterone Pg. 328 The onset of labor is believed to be due to a number of factors involving hormones. The uterine muscle stretches from the increasing size of the fetus, which results in release of prostaglandins. The fetus presses on the cervix, which stimulates the release of oxytocin from the posterior pituitary. Oxytocin stimulation works together with prostaglandins to initiate contractions. Changes in the ratio of estrogen to progesterone occurs, increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal.
20. A nurse is preparing an in-service program about labor and the hormones involved with the initiation of labor. Which information would the nurse include as believing to play a role in the onset of labor? a) Suppression of oxytocin b) Withdrawal of progesterone c) Decrease in fetal cortisol levels d) Suppression of prostaglandin release
d) Continuous labor support Pg. 327 Continuous labor support by a caring nurse or doula can help decrease a woman's anxiety during labor. Anxiety causes the release of catecholamines, which slow down the labor process. The continuous support helps keep the woman focused on what is important as well as provide necessary guidance and education as needed. The massage therapy, prenatal classes, and pharmacologic pain management are all tools that the nurse can use to help the woman.
21. The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client? a) Pharmacologic pain management b) Prenatal classes c) Massage therapy d) Continuous labor support
a) ROA Pg. 332-334 The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.
25. 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? a) ROA b) LOP c) LOA d) ROP
a) Occiput Pg. 332 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.
26. Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? a) Occiput b) Shoulders c) Buttocks d) Brow
d) 8-10 cm Pg. 341 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.
32. 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? a) 0-2 cm b) 3-4 cm c) 5-7 cm d) 8-10 cm
c) 6.5 Pg. 350-352 Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.
44. The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? a) 6.0 b) 5.0 c) 6.5 d) 5.5
d) The frequency of the contractions is every 5 minutes Pg. 366 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.
1. 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? a) The duration of the contractions is every 5 minutes b) The client is in active labor c) The client can be sent home d) The frequency of the contractions is every 5 minutes
a) The client will practice breathing techniques during contractions Pg. 347-361 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.
10. Which client outcome during active and transitional labor is best? a) The client will practice breathing techniques during contractions b) The client will tolerate 8 oz (240 ml) of clear liquids during labor process c) The client will walk in the hall for 15 minutes every 2 hours d) The client will state a pain level of 7 and under during contractions
b) When the cervix is fully dilated Pg. 336-366 To avoid birth trauma, the client is not encouraged to push until the cervix is fully dilated. This is determined on vaginal exam. Once it is noted, there is no need to wait until the fetal head can be seen. The urge to push may be present without full cervix dilation. Labor is not stopped until the health care provider arrives. A nurse can deliver the fetus.
11. At what time is the laboring client encouraged to push? a) When the nurse wants the client to push b) When the cervix is fully dilated c) When the health care provider has arrived d) When the fetal head can be seen
a) Clear to straw-colored fluid Pg. 350-352 The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.
14. A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? a) Clear to straw-colored fluid b) Greenish fluid c) Cloudy white fluid d) Bloody fluid
a) Hemorrhage Pg. 369 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 mother's psyche is a concern during the labor process. At the conclusion of the birth process, the mother's psyche is typically positive. Blood pressure and heart rate as also monitored and can be an indicator of hemorrhage.
15. Which is the most important nursing assessment of the mother during the fourth stage of labor? a) Hemorrhage b) Heart rate c) Blood pressure d) The mother's psyche
b) Dilation (dilatation) of cervix Pg. 341 The best determination of effective contractions is dilation (dilatation) of the cervix. Engagement, membrane rupture, and bloody show may all occur before the cervix has dilated.
16. The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? a) Bloody show b) Dilation (dilatation) of cervix c) Rupture of amniotic membranes d) Engagement of fetus
b) "I feel a lot of pressure" c) "I feel a burning between my legs" d) "I think the baby is coming" e) "I need to have a bowel movement" Pg. 363 The second stage of labor begins with the cervix completely dilated and ends with the birth of the baby. Statements indicating the second stage of labor focus on impending birth. Statements include pressure, burning between the legs, and the need to have a bowel movement. Also, statements that the baby is coming are indicative of impending birth. Cramping is common in early labor. The client's water breaking does not indicate the second stage of labor.
18. Which client statements indicate to the nurse that the client is entering the second stage of labor? Select all that apply. a) "My water has just broken" b) "I feel a lot of pressure" c) "I feel a burning between my legs" d) "I think the baby is coming" e) "I need to have a bowel movement" f) "I feel cramping across my abdomen"
a) "False labor contractions usually occur in the abdomen" Pg. 339 False labor contractions are usually felt in the abdomen, are irregular, and are typically relieved by walking. True labor contractions move from the back to the front of the abdomen, are regular, and aren't relieved by walking.
22. A nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information? a) "False labor contractions usually occur in the abdomen" b) "False labor contractions move from the back to the front of the abdomen" c) "False labor contractions are regular" d) "False labor contractions intensify with walking"
b) Braxton Hicks contractions usually decrease in intensity with walking Pg. 336-339 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.
23. 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 cause "ripening" of the cervix b) Braxton Hicks contractions usually decrease in intensity with walking c) Braxton Hicks contractions get closer together with activity d) Braxton Hicks contractions do not last long enough to be true labor
b) Latent phase Pg. 341 The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage 2 she may remain positive, but the work of labor is very intense.
24. The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? a) Stage two b) Latent phase c) Stage three d0 Transition phase
c) Detection of herpes virus infection Pg. 348 Examine the outer and inner surfaces of her lips carefully to detect herpes lesions (pinpoint vesicles on an erythematous base). Report to her primary care provider if herpetic lesions are present anywhere because although oral lesions are invariably a type I herpes virus (common cold sores), type II (genital) herpes virus needs to be identified as this can be lethal to newborns; a woman primary health care provider may suggest the woman with oral herpes lesions take isolation precautions such as not kissing her newborn until the lesions crust. Be certain to palpate for enlargement of neck lymph nodes to detect the possibility of a respiratory infection. Inspect the mucous membrane of her mouth and the conjunctiva of her eyes for color to see if paleness suggests anemia. Auscultate the woman's lungs to be certain they are clear of rales.
27. A nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment? a) Detection of a respiratory infection b) Detection of anemia c) Detection of herpes virus infection d) Detection of rales
a) Latent phase of the first stage Pg. 341 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 pregnant client. The third stage, placental expulsion, starts after the newborn is born and ends with the separation and birth of the placenta.
28. Assessment of a client 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
d) Placing a wedge under the hips Pg. 349 Due to the lithotomy position, the nursing action of placing a wedge under the hips is correct to avoid supine hypotension. Rubbing the legs or massaging the back can relax the client between intense contractions but those actions do not prevent a complication. Providing a paper bag prevents hyperventilation typically caused by pattern breathing.
3. Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? a) Providing a paper bag b) Massaging the client's lower back c) Rubbing the client's legs d) Placing a wedge under the hips
b) -2 Pg. 334-335 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.
33. A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? a) +2 b) -2 c) +4 d) 0
d) Encourage the client to talk about the birthing experience with the nurse and others Pg. 340 After the birth, the nurse will encourage the client to talk about and share the experience. This "debriefing time" can be an important way to help the client appreciate everything that happened and integrate the experience into their total life. There is no evidence that this client has postpartum depression. Specifically asking about depressive symptoms or family mental health issues, like they were currently present, is inappropriate. While stress is inevitable, assessment of the stress would come before developing potential strategies.
34. A gravida 2, para 2 recently gave birth to a healthy 3304 g (7 lb, 6 oz) female newborn. There were no complications during the birth, and the parent appears to be well. Which action will the nurse take to assess this client's psychologic state after the pregnancy? a) Ask if the client had any depressive symptoms after giving birth the first time b) Ask the client about family history related to mental illness c) Explore potential strategies to minimize stress when returning home d) Encourage the client to talk about the birthing experience with the nurse and others
a) Descent Pg. 334-335 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.
35. Which cardinal movement of delivery is the nurse correct to document by station? a) Descent b) Flexion c) Extension d) Internal rotation
b) Green-colored fluid in the vagina Pg. 346 Green-tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions are expected at this stage of labor.
36. The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? a) Possible maternal infection b) Green-colored fluid in the vagina c) Irregular contractions d) Fetal heart rate
a) Contraction, regular and lasting longer and stronger Pg. 336-339 True labor contraction will progressively get worse and last longer. The pain will come to a point where the woman will not be able to walk or talk through the contractions. Irregular contractions, bloody show, and white vaginal discharge are normal for pregnancy but do not indicate true labor.
37. A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions? a) Contraction, regular and lasting longer and stronger b) Scant amount of thick, white vaginal discharge, no odor c) Contractions, irregular, lasting 15 to 20 seconds d) Bloody mucus in the toilet once earlier in the day
d) Clear liquids but no solid food Pg. 344, 363-364 The nurse should offer clear liquids but no solid foods. She is moving closer to active labor nearing the end of the latent phase. It would not be advisable to offer her solid foods, but she needs to continue her nourishment with fluids to her thirst. Solid foods may lead to nausea and vomiting. Intravenous fluids are too extreme as long as she is able to drink.
38. The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4, three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry? a) Cannot assess with the information given b) Solid food and fluids c) Nothing except for intravenous fluids d) Clear liquids but no solid food
a) "The temperature of the water should be at least 105℉ (40.5℃)" Pg. 378 Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105℉ (40.5℃) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.
39. A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? a) "The temperature of the water should be at least 105℉ (40.5℃)" b) "My cervix should be dilated more than 5 cm before I try using this method" c) "The warmth and buoyancy of the water has a nice relaxing effect" d) "I can stay in the bath for as long as I feel comfortable"
d) "The stitches used will absorb on their own" Pg. The nurse should reassure the woman that the sutures are absorbable and do not need to be removed. The birth attendant uses local anesthesia to numb the perineum for repair, but it is not used periodically after the repair. If the woman had epidural anesthesia, she may not need additional anesthesia for repair. A sterile ice pack, not a warm compress, applied to the perineum after repair can help decrease swelling and pain. There is no need for a sterile dressing.
40. A woman required an episiotomy and it was repaired by the birth attendant. Which instruction will the nurse give to the woman? a) "Try applying some warm compresses to the area for pain relief" b) "You will need an injection of a local anesthetic periodically until it heals" c) "You will have to keep a sterile dressing on the area for 48 hours" d) "The stitches used will absorb on their own"
c) Ensure cervix fully dilated Pg. 366 Before the client begins pushing, the RN should confirm the client's cervix is fully dilated to avoid trauma to the maternal tissues. Evaluating the maternal vital signs and fetal heart status are also important but are not the priority when assessing if the woman is ready to push when the urge begins. The nurse should have already been monitoring the bladder and ensure the client has an empty or close to empty bladder. This can also be evaluated but is not the priority.
41. A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritized at this time? a) Evaluate fetal heart monitor b) Evaluate maternal vital signs c) Ensure cervix fully dilated d) Ensure empty urinary bladder
d) Reassuring; it is associated with normal acid-base balance Pg. 350-352 The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus.
42. A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? a) Damaging; it is frequently associated with fetal neurological damage b) Worrisome; it may be associated with metabolic acidosis c) Critical; it represents metabolic acidosis d) Reassuring; it is associated with normal acid-base balance
a) Vaginal rugae stretch and smooth out c) The cervix dilates to 10 cm d) The cervix softens Pg. 328 Changes in the female body occur to allow the passage of the fetus down the birth canal. Vaginal rugae stretch and smooth out allowing for the ability of the fetus to descend. The cervix thins to a maximum of 10 cm and the cervix softens, becoming more accepting of the transition through by the fetus. Full effacement is noted as 100%. Round ligaments stretch to accommodate the expanding uterus and frequently result in discomfort in the antepartum period.
43. Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply. a) Vaginal rugae stretch and smooth out b) Effacement is noted as 0% c) The cervix dilates to 10 cm d) The cervix softens e) Round ligaments contract
b) Lightening d) Backache e) Bloody show Pg. 336-340 The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilation (dilatation). Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.
45. A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. a) Constipation b) Lightening c) Weight gain d) Backache e) Bloody show
d) Complete cervical dilation (dilatation) and time of fetal birth Pg. 342 The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.
47. 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) Time of mucus plug expulsion and full cervical dilation c) Effacement time and time when contractions are regular d) Complete cervical dilation (dilatation) and time of fetal birth
c) Women should be able to move about freely throughout labor Pg. 360 Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.
5. A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? a) The support person's access to the client should be limited to prevent the client from becoming overwhelmed b) Routine intravenous fluid should be implemented c) Women should be able to move about freely throughout labor d) A woman should be allowed to assume a supine position
c) "It is important to try to urinate every 2 hours because you might not feel the urge" Pg. During labor, pressure from the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Therefore, it is important to have the pregnant client void approximately every 2 hours during labor to avoid overfilling, because overfilling can decrease postpartum bladder tone. Bladder filling is not affected, and there is no need to give a urine specimen with each voiding. Insensible fluid loss does occur with sweating, but is not associated with the need for voiding every 2 hours.
6. Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide? a) "Even though you are sweating, you still need to urinate at least every hour" b) "You need to give a urine specimen each time you urinate so we can check for infection" c) "It is important to try to urinate every 2 hours because you might not feel the urge" d) "You need to get up and walk around a bit so that your bladder can get filled more fully"
c) Change the position of the client Pg. 359 Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.
7. The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? a) Increase her IV fluids b) Notify the primary care provider c) Change the position of the client d) Administer oxygen
b) Ecchymosis with edema on the scalp is where the infant was pushed out of the canal Pg. 332 Ecchymosis and edema are normal findings when located on the part that was presenting in labor. The infant was ROA, so the head was the presenting part and has normal bruising and swelling. The effects of birth are normal, and are not of concern. Communicate to the parents that it is similar to a bruise or a blister. This sign is not indicative of the use of forceps.
8. The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor? a) Edema is swelling and caused by unusual trauma; the provider must have used forceps b) Ecchymosis with edema on the scalp is where the infant was pushed out of the canal c) The infant needs to be assessed by the health care provider d) Ecchymosis indicates a blood disorder and the infant will need testing
a) In the active phase of the first stage of labor Pg. 341-363 The most pain medication is given during the active phase of labor. Implementing general comfort measures with opioid analgesia or epidural anesthesia is common. During the transition phase, the woman's contractions become intense and include an urge to push. A goal for this period is that the woman's pain will be manageable. Comfort measures are most important as opiods are not given at this advanced stage. Luckily, this phase is typically the shortest. The latent phase is the early portion of labor. This is frequently completed at home with comfort measures provided by the support person. The second stage of labor begins with full dilation (dilatation) and ends with the birth.
9. At which time does the nurse anticipate that the woman will need the most pain relief measures? a) In the active phase of the first stage of labor b) During the transition phase of the first stage of labor c) In the latent phase of the first stage of labor d) At the beginning of the second stage of labor
