Chapter 13 prep u

A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?

transverse (biparietal) Explanation: The anteroposterior diameter of the pelvis, a space approximately 11 cm wide, is the narrowest diameter at the pelvic inlet, so the best presentation for birth is when the fetus presents a transverse (biparietal) diameter (the narrowest fetal head diameter, at 9.25 cm) to this. The other diameters of the fetal skull that are listed are all larger.

A nulliparous client at 37 weeks gestation calls the labor and delivery unit to report she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?

Contraction, regular and lasting longer and stronger Explanation: 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.

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

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 is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? The fetus is floating high in the pelvis. The fetus is in the true pelvis and engaged. The client is fully effaced. The fetus has descended down the birth canal.

The fetus is in the true pelvis and engaged. Explanation: 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.

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care? No nursing care is needed to be done during this time. A woman should be left entirely alone during this period. A woman may spend time thinking about what is happening to her. A woman will rarely speak or laugh during this period.

A woman may spend time thinking about what is happening to her. Explanation: Women need a support person with them during all stages of labor.

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?

Cervix Explanation: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

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.

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?

Nothing. Normal time for stage three is 5 to 30 minutes. Explanation: Following birth, the placenta is spontaneously expelled within 5 to 30 minutes, so there is no problem with this client. No further interventions are needed.

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?

decrease in circulation and perfusion to the fetus Explanation: 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.

During the examination, the health care provider mentions the fetus has a good attitude. The nurse explains to the parents that this means:

the posture of the fetus is with all joints flexed for birth. Explanation: The attitude refers to the posturing of the joints, either flexion or extension, and the relationship of fetal parts to one another. The most common fetal attitude when labor begins is with all joints flexed. This normal fetal position is most favorable for vaginal brith, presenting the smallest fetal skull diameters to the pelvis.

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations. Explanation: 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 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 Explanation: 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.

When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis? Select all that apply.

round-shaped inlet dull ischial spines wide pubic arch Explanation: The features of a gynecoid pelvis are oval-shaped inlet, dull ischial spines, and wide pubic arch. The birth of a baby is easiest in a gynecoid pelvis. Straight sacrum and convergent side walls are seen in an android pelvis.

A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? Select all that apply. apprehension mixed with excitement cervical effacement of 70% strong desire to push irritability with restlessness cervical dilation (dilatation) of 6 cm

strong desire to push irritability with restlessness Explanation: A strong desire to push occurs most often in the transition 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 (dilatation) from 4 to 7 cm characterizes 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.

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:

the buttocks are presenting first with both legs extended up toward the face. Explanation: In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.

A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. The nurse predicts the woman is close to labor based on which assessment finding?

Nesting Explanation: Nesting is the activity or burst of energy women often experience prior to the onset of labor. The client could express this in her words or by what her activities had been at home. Dilation, effacement, and cervical ripening are all observable by the provider upon exam.

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? "She is doing well and is in the second stage; it could be anytime now." "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." "She is still in early latent labor and has much too long to go to tell when she will give birth." "She is in active labor; she is progressing at this point and we will keep you posted."

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

A primigravidia 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." 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.

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely." Explanation: Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilatation but not effacement. Therefore, just saying, "no further dilatation" 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 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? "Cervical thinning is a sign that you are in true labor." "Your cervix thins so that your contractions can increase." "It thins to let your baby change positions during labor." "You need the cervix to thin so it can stretch more easily."

"You are still 2 cm dilated, but the cervix is thinning out nicely." Explanation: Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilation (dilatation) but not effacement. Therefore, just saying, "no further dilation (dilatation)" 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.

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?

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 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.

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?

Any woman, even one who has taken natural birth classes, has 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 primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?

Ask the woman to describe why she believes that she is in labor. Explanation: The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as the client may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not the client is in labor. The client may be in false labor, and more information should be obtained before the client is brought to the hospital.

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?

Braxton Hicks contractions usually decrease in intensity with walking. Explanation: 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.

A primigravida has an office appointment at 39 weeks' gestation. Which assessment data is most definitive of the onset of labor? Expulsion of the mucus plug. The fetal head is engaged in the pelvis. Cervical ripening is noted on examination. The mother reports frequent urination.

Cervical ripening is noted on examination. Explanation: Clinical signs that labor is approaching include ripening or softening of the cervix with effacement and dilation (dilatation). Frequent urination is common during engagement where the fetal head is in the pelvis. This is common up to 2 weeks before true labor begins. Expulsion of the mucus plug also is common a week or two before labor begins.

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? Prepare the client for cesarean birth of the fetus. Auscultate fetal heart rate (FHR) in the left upper quadrant. Educate the client this fetal position may result in a longer labor. Continue to monitor the progress of 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 caring for a client who is experiencing a noneventful labor process. Which assessment findings may occur as the client progresses through the stages of labor? Select all that apply. Hyperventilation Increased white blood cell count Dry mucous membranes Increased urine specific gravity Nausea Diuresis

Dry mucous membranes Nausea Increased white blood cell count Increased urine specific gravity Hyperventilation Explanation: The nurse is correct to identify that normal changes occur during the labor process. Due to mouth breathing and drinking limited fluids, if any, dehydration with dry mucous membranes and an elevated urine specific gravity are common. Since labor prolongs gastric emptying, the client may experience nausea. An increase in the white blood cell stemming from the immune response is common. Concentrated urine and decreased urine production are common, not diuresis.

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

Engagement Explanation: 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 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?

ROA Explanation: 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.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? The station in which the fetus is located Maternal heart rate and blood pressure Maternal request for pain medication Fetal heart rate in relation to contractions

Fetal heart rate in relation to contractions Explanation: The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.

Which is the most important nursing assessment of the mother during the fourth stage of labor? Heart rate Blood pressure The mother's psyche Hemorrhage

Hemorrhage Explanation: 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.

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?

Latent phase Explanation: 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 two she may remain positive, but the work of labor is very intense.

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 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.

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? Cephalohematoma Molding Caput succedaneum Vertex presentation

Molding Explanation: 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.

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 Explanation: 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 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 2020 related to women in labor?

Reduce the rate of cesarean births among low-risk births. Explanation: Healthy People 2020 has two goals related to cesarean births in the United States. They are to reduce the rate of cesarean births among low-risk women and reduce the rate of cesarean births among women who have had a prior cesarean birth. Immunizations and genetic counseling are not associated with women in labor.

A nurse is monitoring a woman in labor. Which assessment finding is most concerning to the nurse? Temperature is 101.6°F (38.7°C). Blood pressure is 128/82 mm Hg. Respiratory rate is 22 breaths/minute. Client begins vomiting.

Temperature is 101.6°F (38.7°C). Explanation: 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 woman progresses through birth, numerous physiologic responses occur that assist her to adapt to the laboring process. Some of these changes include heart rate increasing by 10 to 20 beats per minute; 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 transition phase, due to decreased gastric motility.

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?

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.

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?

The cervix takes around 12 to 16 hours to dilate during first pregnancy. Explanation: The labor of a first-time-pregnant woman lasts longer because during the first pregnancy the cervix takes between 12 and 16 hours to dilate completely. The intensity of the Braxton Hicks contractions stays the same during the first and second pregnancies. Spontaneous rupture of membranes may occur before the onset of labor during each birth, not only during the first birth.

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

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.

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?

Women should be able to move about freely throughout labor. Explanation: 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.

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?

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.

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? lightening cervical ripening and softening bloody show Braxton Hicks contractions

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.

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?

crowning Explanation: 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 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?

dilation of cervix diameter to 10 cm Explanation: The first stage of labor terminates with the dilation of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occurs 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.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration Explanation: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.

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?

effacement Explanation: The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. 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.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest?

head elevated, grasping knees, breathing out Explanation: An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.

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 Explanation: 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 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 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 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 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.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie Explanation: The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:

lightening. Explanation: Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position. In primiparas, lightening can occur two weeks or more before labor begins; among multiparas, it may not occur until 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 women evaluated, especially if she is less than 38 weeks pregnant.

A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? hypoxia of the contracting uterine muscles pain from the dilation (dilatation) or stretching of the cervix distention of the vagina and perineum pressure on the lower back, buttocks, and thighs

pain from the dilation (dilatation) or stretching of the cervix Explanation: In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.

A client comes to the emergency department reporting strong contractions that have lasted for the past 2 hours. Which assessment will indicate to the nurse that the client is in true labor? 1:5 uterine contractions progressive cervical dilation (dilatation) and effacement pink show increased fetal activity

progressive cervical dilation (dilatation) and effacement Explanation: True labor is defined as the onset of regular uterine contractions that cause progressive cervical dilation (dilatation) and effacement. Pink show may occur 24 to 48 hours prior to birth. Increased fetal activity can occur at any stage. Thus, these are not indicators of true labor. There is no defined ratio of contractions when differentiating true from false labor.

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?

restoration of blood flow to uterus and placenta Explanation: 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 of the cervix are other processes that occur during uterine contractions.

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?

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.

A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?

to constrict the uterine blood vessels Explanation: The nurse must massage the client's uterus briefly after placental expulsion to constrict the uterine blood vessels and minimize the possibility of hemorrhage. Massaging the client's uterus will not lessen the chances of conducting an episiotomy. In addition, an episiotomy, if required, is conducted in the second stage of labor not the third. The client's uterus may appear boggy only in the fourth stage of labor not in the third stage. Ensuring that all sections of the placenta are present and that no piece is left attached to the uterine wall is confirmed through a placental examination after expulsion.