chapter 13
Which change in client status suggests that labor is anticipated? -The woman can breathe easier throughout the day. -The woman does not have to urinate as often. -Uterine contractions occur but diminish when resting. -The woman is anxious about the birth process.
-The woman can breathe easier throughout the day. Symptoms that the woman is able to breathe easier strongly suggest lightening. Lightening means that the fetus has dropped into the pelvis or is engaged. Typically when the fetus is in the pelvis, it impinges on the bladder causing the need for more frequent urination. Braxton Hicks contractions are the first contractions that may be present for some time. These contractions occur but can diminish when walking or when the woman's position changes. Anxiety and anticipation are commonly felt throughout pregnancy.
A nurse is caring for a client in her fourth stage of labor. Which assessment(s) indicates a normal physiologic change occurring during the fourth stage of labor? Select all that apply. -decrease in the pulse rate -increase in the blood pressure -decreased intra-abdominal pressure -well-contracted uterus in the midline mild -uterine cramping and shivering
-decrease in the pulse rate -decreased intra-abdominal pressure -well-contracted uterus in the midline -mild uterine cramping and shivering 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, decreased intra-abdominal pressure, and a stable blood pressure within normal limits. The pulse is usually typically slower than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss.
A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours? -"You are still 2 cm dilated, but the cervix is thinning out nicely." -"There has been no further dilation; effacement is progressing." -"You haven't dilated any further, but hang in there; it will happen eventually." -Don't mention anything to the client yet; wait for further dilatation to occur.
"You are still 2 cm dilated, but the cervix is thinning out nicely." Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, remember most women are aware of the word dilation (dilatation) but not effacement. Just saying, "no further dilation", therefore, is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening and that's just as important" is the same report given in a positive manner.
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? -First -Second -Third -Fourth
-Third Stage three begins with the birth of the baby and ends with delivery of the placenta.
TAKE NOTE!
An infant born between 34 0/7 and 36 6/7 weeks' gestation is identified as "late preterm" and experiences many of the same health issues as other preterm birth infants
second stage of labor
From 10cm dilation till birth, the pushing stage. may last up to 3 hours.
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 the woman in labor to save energy. -It facilitates vaginal examinations. -It facilitates external belt adjustment. -It helps to rotate the fetus in a posterior position.
It helps to rotate the fetus in a posterior position. 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.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? -The contraction pains are 2 minutes apart and 1 minute in duration. -The client reports back pain, and the cervix is effacing and dilating. -The contraction pains have been present for 5 hours, and the patterns are regular. -After walking for an hour, the contractions have not fully subsided.
The client reports back pain, and the cervix is effacing and dilating. True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.
oblique lie
The fetal long axis is at an angle to the bony inlet, and no palpable fetal part is presenting. This lie is usually transitory and occurs during fetal conversion between other lies. A fetus in a transverse or oblique lie position cannot be delivered vaginally.
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? -engagement -descent -restitution -crowning
crowning Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? -decrease in arterial carbon dioxide pressure -increase in fetal breathing movements -increase in fetal oxygen pressure -decrease in circulation and perfusion to the fetus
decrease in circulation and perfusion to the fetus 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. The nurse should monitor for an increase, not a decrease, in arterial carbon dioxide pressure. The nurse should also monitor for a decrease, not an increase, in fetal breathing movements throughout labor. The nurse should monitor for a decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen.
False labor
is a condition occurring during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected. In contrast, true labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity.
Lightening
occurs when the fetal presenting part begins to descend into the true pelvis. The uterus lowers and moves into a more anterior position. The shape of the abdomen changes as a result of the change in the uterus. With this descent, the woman usually notes that her breathing is much easier and that there is a decrease in gastric reflux. However, she may complain of increased pelvic pressure, leg cramping, dependent edema in the lower legs, and low back discomfort. She may notice an increase in vaginal discharge and more frequent urination. In primiparas, lightening can occur 2 weeks or more before labor begins; among multiparas, it may not occur until labor starts
Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? -decrease in vaginal secretions -development of a membrane further closing the cervix -rupture of amniotic membranes -decrease in duration of contractions
rupture of amniotic membranes The nurse should identify the rupture of amniotic membranes as the best indicator of approaching labor. In labor, the client experiences increased vaginal secretions, increased duration of contractions, and also loss of mucus plug.
fourth stage of labor
the first 1-4 hours after birth of the newborn, time of maternal physiologic adjustment.
Dilation
the opening or enlargement of the external cervical os
Fetal Lie
the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother
Uterine contractions have two main functions:
to dilate the cervix and to push the fetus through the birth canal
Which feature would alert the nurse that the client is in the transition phase of labor? -reduction of rectal pressure -decrease in the bloody show -enthusiasm in the client -beginning urge to bear down
beginning urge to bear down The beginning of the urge to bear down is a feature associated with the transition phase of labor. The transition phase is the last phase of the first stage of labor. In this phase, the process of cervical dilation (dilatation) is completed. During this phase the client experiences an increase in rectal pressure, an increase in the bloody show, and an urge to bear down. The contractions are stronger and hence the client feels irritable, restless, and nauseous. The client feels enthusiastic during the latent phase and not the transition phase.
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 and taking a shower -remain irregular with the same intensity -subside when walking around and use the lateral position cause ---discomfort over the top of uterus
increase even if relaxing and taking a shower True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.
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." 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.
transverse lie
The long axis of the fetus is at a right angle to the mother's long axis. This is incompatible with a vaginal delivery if the fetus remains in this position
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 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.
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 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.
first stage of labor
The first stage ends when the cervix is dilated to 10 cm in diameter and is large enough to permit the passage of a fetal head of average size. The fetal membranes usually rupture during the first stage, but they may have burst earlier or may even remain intact until birth. For the primigravida, the first stage of labor can last up to 20 hours without being considered prolonged. However, this time can vary widely; for the multiparous woman, it can last up to 14 hours.
Which occurs as a result of contraction decrement? Select all that apply. -The mother feels the contraction intensifying. -Blood flow to the fetus improves. -The fetus is pushed down the birth canal. -Fetal heart rate should return to baseline. -The mother feels a gush of water in the perineal area.
-Blood flow to the fetus improves. -Fetal heart rate should return to baseline. When there is a contraction decrement, the contraction intensity is decreasing. Blood flow improves to the fetus and the fetal heart rate should return to baseline. The fetus moves down the birth canal propelled by the intense contractions. When the bag of waters breaks, the mother will feel a gush of water. This first gush typically appears after the water breaks when the contraction is strong. Continued water leakage may occur with each contraction.
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is: -1 cm above the ischial spines. -1 cm below the ischial spines. -1 cm below the pubic bone. -1 cm above the pubic bone.
1 cm above the ischial spines. Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and referred to as a minus or plus, depending on its location above or below the ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spine, it is recorded as plus stations. Therefore this fetus is 1 cm above the ischial spines.
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. 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.
longitudinal lie
The fetal long axis is parallel to the mother's long axis. The fetus is either in a breech or vertex presentation
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: -duration. -intensity. -frequency. -peak.
-frequency. Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.
During which time is the nurse correct to document the end of the third stage of labor? -Following fetal birth -When pushing begins -At the time of placental delivery -When the mother is moved to the postpartum unit
At the time of placental delivery 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.
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? -False pelvis -Cervix -Perineum -Uterus
Cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
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 -Caput succedaneum -Cephalohematoma -Vertex presentation
Molding The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head.
Traditionally, the critical factors that affect the process of labor and birth are outlined as the "five Ps:"
Passageway (birth canal) Passenger (fetus and placenta) Powers (contractions) Position (maternal) Psychological response
third stage of labor
delivery of placenta, usually last 5-10 minutes but may take up to 30 minutes.
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 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.
Fetal Presentation
refers to the body part of the fetus that enters the pelvic inlet first (the "presenting part"). This is the fetal part that lies over the inlet of the pelvis or the cervical os. Knowing which fetal part is coming first at birth is critical for planning and initiating appropriate interventions.
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? -relaxin -progesterone -oxytocin -prolactin
relaxin As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth. Progesterone, oxytocin, and prolactin are not involved.
During the second stage of labor, a woman is generally: -very aware of activities immediately around her. -anxious to have people around her. -no longer in need of a support person. -turning inward to concentrate on body sensations.
turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.
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 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 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? -effacement and dilation (dilatation) of the cervix -shortening of the upper uterine segment -reduction in length of the cervical canal -restoration of blood flow to uterus and placenta
-restoration of blood flow to uterus and placenta The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation (dilatation) of the cervix are other processes that occur during uterine contractions.
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 -Slows when the woman changes position -Occurs in an irregular pattern -Lasts about 20 to 25 seconds
Radiates from the back to the front 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.
The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? -flexion -engagement -extension -expulsion
engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.
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? -"Your cervix thins so that your contractions can increase." -"You need the cervix to thin so it can stretch more easily." -"It thins to let your baby change positions during labor." -"Cervical thinning is a sign that you are in true labor."
"You need the cervix to thin so it can stretch more easily." 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 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? -Give the medication as an intramuscular injection using the Z-track technique. -Administer the medication piggybacked into a primary IV line using a pump. -Give the medication orally every hour for the first 4 hours. -Assist with insertion of a central venous access device for administration.
Administer the medication piggybacked into a primary IV line using a pump 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 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. -Hold the breath while pushing during contractions. -Begin pushing as soon as the cervix has dilated to 8 cm. -Pant while pushing.
Push with contractions and rest between them Make sure the woman pushes with contractions and rests between them. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to her heart because of increased intrathoracic pressure, which could then also interfere with blood supply to the uterus. It is important for women to understand they should not bear down with their abdominal muscles to push until the cervix is fully dilated, which is 10 cm, not 8 cm. Panting limits the ability to push and is to be encouraged only when it is desirable to delay labor, such as when a nuchal cord is present.
