Midterm prep_Chapter 13: Labor and Birth Process

Temperature is 101.6°F (38.7°C). 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.

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

Buttocks - The second letter of LSA denotes the presenting part. In this case, it is "S" which is for sacrum or buttocks. "O" refers to the occiput; "M" would be used to refer to the chin. "A" would be used to refer to the acromion process.

A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting? buttocks acromion process occiput chin

Braxton Hicks contractions usually decrease in intensity with walking. - 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.

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. Braxton Hicks contractions do not last long enough to be true labor. Braxton Hicks contractions cause "ripening" of the cervix. Braxton Hicks contractions get closer together with activity.

Reduce the rate of cesarean births among low-risk women. Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in 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 2030 related to women in labor? Reduce the rate of cesarean births among low-risk women. Ensure care during labor includes immunizations. Ensure all couples receive preconception genetic counseling. Encourage women with previous cesareans to always have a cesarean.

Descent - 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.

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

the buttocks are presenting first with both legs extended up toward the face. 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 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating: one leg is presenting. one arm is presenting. the fetus is sitting cross-legged above the cervix. the buttocks are presenting first with both legs extended up toward the face.

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.

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? After walking for an hour, the contractions have not fully subsided. 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.

ROA 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.

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? LOP ROA LOA ROP

lightening. 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. It is a premonitory sign of labor and is not associated with rupture of membranes or placental previa.

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: start of labor. lightening. rupture of the membranes. placenta previa.

"I feel pressure in my vagina when I have the contraction." True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? "The contractions lessen after I drink a large glass of water." "I feel pressure in my vagina when I have the contraction." "I feel the tightening primarily in the front of my belly." "I will have a strong one and then the next one will be weaker."

These contractions help in softening and ripening the cervix. - Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? These contractions help in softening and ripening the cervix. These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions make maternal breathing easier.

8-12 weeks - The posterior fontanel (fontanelle) is a triangular-shaped area at the back of the skull. The nurse should inform the client that the posterior fontanel (fontanelle) normally closes by 8 to 12 weeks after birth, and if there is delay the primary health care provider should be notified.

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel (fontanelle) will close. Which time span is the normal duration for the closure of the posterior fontanel (fontanelle)? 8 to 12 weeks 4 to 6 weeks 12 to 14 weeks 14 to 18 weeks

Third - Stage three begins with the birth of the baby and ends with delivery of the placenta.

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? Third First Second Fourth

catecholamines - Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds? relaxin catecholamines prostaglandins oxytocin

pain from the dilation or stretching of the cervix - 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 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? pressure on the lower back, buttocks, and thighs hypoxia of the contracting uterine muscles pain from the dilation (dilatation) or stretching of the cervix distention of the vagina and perineum

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

transition phase - The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation (dilatation) in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation (dilatation) of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.

A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? early phase transition phase active phase latent phase

increase in respiratory rate increase in heart rate increase in blood pressure - 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 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 gastric emptying and pH increase in blood pressure increase in respiratory rate slight decrease in body temperature

release of oxytocin by the pituitary prostaglandin production in the myometrium - The possible causes for the onset of labor include an increase in the fetal cortisol levels, release of oxytocin by the posterior pituitary, and the production of prostaglandins. Progesterone withdrawal, and not an increase, initiates labor. There is a rise in the estrogen levels at 34 to 35 weeks of pregnancy. Estrogen stimulates prostaglandin production and also promotes the release of oxytocin.

A nurse is conducting an in-service program for a group of nurses working in the prenatal clinic. When discussing the theories about the onset of labor, the nurse points out which factor as a possible cause? Select all that apply. release of oxytocin by the pituitary decrease in the fetal cortisol levels prostaglandin production in the myometrium increase in the production of progesterone fall in the estrogen at 34 to 35 weeks of pregnancy

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.

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? progesterone prolactin oxytocin relaxin

"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, 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.

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? Don't mention anything to the client yet; wait for further dilation (dilatation) to occur. "You haven't dilated any further, but hang in there; it will happen eventually." "You are still 2 cm dilated, but the cervix is thinning out nicely." "There has been no further dilation (dilatation); effacement is progressing."

Cervical ripening and softening - 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.

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? Braxton Hicks contractions bloody show lightening cervical ripening and softening

first, active - Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor, which is characterized by cervical dilation of 4 to 7 cm. Regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and at -1 station. Second stage of labor begins when the cervix is 10 cm dilated. The first latent phase is characterized by the onset of regular contractions and cervical dilation of 0 to 4 cm. Third stage of labor is from birth of the infant to completed delivery of the placenta.

A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor? first, latent second third first, active

increased risk of infection - After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

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

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

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

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 of the cervix are other processes that occur during uterine contractions.

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? reduction in length of the cervical canal restoration of blood flow to uterus and placenta shortening of the upper uterine segment effacement and dilation (dilatation) of the cervix

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 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 facilitates external belt adjustment. It helps the woman in labor to save energy. It helps to rotate the fetus in a posterior position. It facilitates vaginal examinations.

Long axis of fetus is perpendicular to that of client. If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? Long axis of fetus is at 45° to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is at 60° to that of client.

The cervix takes around 12 to 16 hours to dilate during first pregnancy. The labor of a primigravida 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 pregnant client wants to know why the labor of a primigravida 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? Contractions are stronger during the first pregnancy than the second. Braxton Hicks contractions are not strong enough during first pregnancy. Spontaneous rupture of membranes occurs during first pregnancy. The cervix takes around 12 to 16 hours to dilate during first pregnancy.

occurring about every 5 minutes. 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 woman evaluated, especially if she is less than 38 weeks' pregnant.

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: lasting about 30 seconds. occurring in the abdomen and groin. occurring about every 5 minutes. relieved by walking.

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.

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? Lasts about 20 to 25 seconds Occurs in an irregular pattern Slows when the woman changes position Radiates from the back to the front

Cervical ripening is noted on examination - 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.

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

Buttocks The second letter indicates the presenting part. The letter "S" indicates the sacrum or buttocks as the presenting part. The fetal head would be noted by the letter "O," indicating occiput. The fetal chin would be noted by the letter "M," indicating mentum. The fetal shoulder would be noted by the letter "A," indicating the acromion process. The first letter indicates the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The last letter specifies whether the presenting part is facing the anterior (A) or posterior (P) portion of the maternal pelvis or whether it is in a transverse (T) position. Application Chapter 15

After learning that her fetus is in the LST position, the client asks the nurse what this means. Which structure will the nurse point out is presenting first? head shoulder chin buttocks

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.

During the second stage of labor, a woman is generally: very aware of activities immediately around her. no longer in need of a support person. turning inward to concentrate on body sensations. anxious to have people around her.

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.

During which time is the nurse correct to document the end of the third stage of labor? At the time of placental delivery When pushing begins Following fetal birth When the mother is moved to the postpartum unit

Latent stage Active stage Transition stage Second stage Third stage - The latent stage is the beginning of labor from approximately 0 cm dilated to 3 to 4 cm dilated. The active stage is from when the cervix is 4 cm dilated to 8 cm dilated. Active labor begins to become more uncomfortable for the patient and the contractions are usually stronger, longer, and closer together. Transition is approximately 8 to 10 cm. The second stage of labor is from when the patient is 10 cm dilated to delivery of the baby. The third stage of labor is from the delivery of the baby to the delivery of the placenta.

Place the following stages of labor in order from what occurs first to last. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1third stage 2active stage 3second stage 4transition stage 5latent stage

Fetal position 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. 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.

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? Fetal size Fetal position Fetal station Fetal attitude

+4 - As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? +4 +1 0 -5

passageway, passenger, position, powers, psych - The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).

The five "Ps" of labor are: passageway, passenger, position, powers, psych. passenger, position, powers, presentation, psych. passenger, position, presentation, pushing, psych. passenger, posture, position, presentation, psych.

lie 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.

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? position presentation attitude lie

Continue to monitor the progress of labor. - 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 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. Educate the client this fetal position may result in a longer labor. Continue to monitor the progress of labor. Auscultate fetal heart rate (FHR) in the left upper quadrant.

"She is in active labor; she is progressing at this point and we will keep you posted." - 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.

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 in active labor; she is progressing at this point and we will keep you posted." "She is still in early latent labor and has much too long to go to tell when she will give birth." "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." "She is doing well and is in the second stage; it could be anytime now."

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.

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? 3 to 4 8 to 10 5 to 7 0 to 2

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.

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? engagement flexion expulsion extension

The fetus is in the true pelvis and engaged. - 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 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 fetus has descended down the birth canal. The client is fully effaced.

Dry mucous membranes Nausea Increased white blood cell count Increased urine specific gravity Hyperventilation 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 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. Dry mucous membranes Diuresis Hyperventilation Nausea Increased urine specific gravity Increased white blood cell count

The cervix is softening - The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.

The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? The cervix is dilating The uterus is relaxing The perineum is relaxing The cervix is softening

Longitudinal The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie. In the transverse lie, the fetus lies crosswise to the maternal spine. An oblique lie is between the two. There is not an obtuse lie.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? Transverse Oblique Obtuse Longitudinal

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.

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: frequency. intensity. peak. duration.

Complete cervical dilation (dilatation) and time of fetal birth - The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? Admission time and time of fetal birth Time of mucus plug expulsion and full cervical dilation Complete cervical dilation (dilatation) and time of fetal birth Effacement time and time when contractions are regular

Oxytocin Progesterone Prostaglandins - There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.

The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. Testosterone Oxytocin Prostaglandins Insulin Progesterone Thyroxine

second - The second stage of labor is between full dilation (dilatation) and birth of the infant. This woman has completed transition and is in the second stage of labor. The third stage begins with the birth of the baby and ends with delivery of the placenta. The active phase begins at 4 cm cervical dilation (dilatation) and ends when the cervix is dilated 8 cm. During the transition phase, contractions reach their peak of intensity, occurring every 2 to 3 minutes with a duration of 60 to 70 seconds, and a maximum cervical dilation (dilatation) of 8 to 10 cm occurs. Both the active and transition phases occur during the first stage of labor.

The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? second third active transition

A cephalohematoma Blood collection under the scalp of the newborn from birth trauma is called a cephalohematoma. Instructions for care include simple observation of the area. The cephalohematoma will subside in a couple of weeks and may take a couple of months to completely go away. There is no brain damage associated with a cephalohematoma. A caput succedaneum is swelling, without blood collection, of the soft tissue of the head.

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? developmental delay a cephalohematoma a caput succedaneum wrapping of the head

increased white blood cell count - The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, not decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? increased blood glucose levels increased white blood cell count increased blood coagulation time decreased plasma fibrinogen levels

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.

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 restitution engagement descent

descent, flexion, internal rotation, extension, external rotation, expulsion - The six cardinal movements of the fetus, in order, are descent, flexion, internal rotation, extension, external rotation, and expulsion.

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: descent, flexion, internal rotation, extension, external rotation, expulsion descent, flexion, external rotation, extension, internal rotation, expulsion internal rotation, descent, extension, flexion, external rotation, expulsion internal rotation, flexion, descent, extension, external rotation, expulsion

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

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? Uterus False pelvis Cervix Perineum

Nothing. Normal time for stage three is 5 to 30 minutes. 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.

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. Increase the IV tocolytic to help in expulsion of the placenta. Do a vaginal exam to see if the placenta is stuck in the birth canal. Notify the primary care provider of the problem.

positive reinforcement - Any woman, even one who has taken natural childbirth 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.

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? their significant other beside them intense nursing care positive reinforcement just to be left alone

effacement 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.

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? molding effacement dilation (dilatation) crowning

Decreasing pH throughout labor Changing heart rate during contractions Excretion of respiratory tract mucus Normal labor stresses the fetus in several ways. Labor increases intracranial pressure due to the head meeting resistance, it reduces blood flow which increases blood pH, and also slows the heart rate during the height of contractions. Since this is a vaginal birth, each contraction squeezes respiratory secretions (including mucus) from the respiratory tract. The newborn may have slight cyanosis of the hands and feet until warmed but not centrally seen circumoral cyanosis.

Which fetal adaptation is anticipated in a vaginal birth? Select all that apply. Excretion of respiratory tract mucus Decreased intracranial pressure Decreasing pH throughout labor Circumoral cyanosis after birth Changing heart rate during contractions

Hemorrhage 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

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