NUR 128 - Labor and Delivery, Ch. 13, 14, 15, 16 -- Ricci, Kyle & Carman Fourth Edition

When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories?

change in estrogen-to-progesterone ratio Explanation: One of the theories suggests that labor is initiated by a change in the estrogen-to-progesterone ratio. The number of oxytocin receptors have been noted to increase. Estrogen levels also increase, which in turn increases myometrial sensitivity to oxytocin. Prostaglandin levels also increase, which in turn leads to myometrial contractions.

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 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.

A client is ready to push. The nurse instructs her to push vigorously and grunt and breathe out during a pushing effort. What would be important to monitor on the client while she is pushing vigorously?

fatigue Explanation: Recent research has revealed that vigorous pushing techniques that employ the Valsalva maneuver are associated with increased fatigue. LOC is not normally affected and it is normally impractical to monitor blood pressure while the client is pushing vigorously.

Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH?

7.2 Explanation: Umbilical cord blood acid-base analysis is considered the most reliable indication of fetal oxygenation and acid-base condition at birth. The normal mean pH value range is 7.2 to 7.3.

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.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. Explanation: The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

Vaginal examination Explanation: A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next. Explanation: Measuring from the beginning of one contraction to the next marks the time between contractions.

A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?

"After birth it is easier to develop an infection in the urinary system; we need to see you today." Explanation: The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner.

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." Explanation: A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." Explanation: The nurse should explain to the client that lochia rubra is a deep red mixture of mucus, tissue debris, and blood. Discharge consisting of leukocytes, decidual tissue, RBCs, and serous fluid is called lochia serosa. Discharge consisting of only RBCs and leukocytes is blood. Discharge consisting of leukocytes and decidual tissue is called lochia alba.

A nurse is providing care to a postpartum woman who is breastfeeding her 1-day old neonate. While observing the interaction, the woman says to the nurse, "I have noticed some tingling in both of my breasts just before my baby starts to feed and then for a bit during the feeding. What is happening?" Which response by the nurse would be appropriate?

"What you are feeling is the normal let-down reflex when milk is released." Explanation: Typically, during the first 2 days after birth, the breasts are soft and nontender. The woman may also report a tingling sensation in both breasts, which is the "let-down reflex" that occurs immediately before or during breastfeeding. This tingling is not a sign of infection or blockage of the milk ducts. Engorgement is a postnatal physiologic painful condition in which distension and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation. Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours.

A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?

"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy." Explanation: The abdominal organs, including the diaphragm, typically return to prepregnancy state within 1 to 3 weeks after birth. Discomforts such as shortness of breath and rib aches lessen, and tidal volume and vital capacity return to normal values.

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?

"You need the cervix to thin so it can stretch more easily." Explanation: 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 fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2 Explanation: 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.

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. Explanation: 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.

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?

110 to 160 bpm Explanation: The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

A nurse is providing care to a woman who is 6 hours postpartum. The nurse suspects urinary retention based on which finding?

50 to 70 mL urine per void every hour Explanation: Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow and a need for catheterization. A uterus at the level of the umbilicus, moderate lochia rubra, and clear yellow urine are normal findings.

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?

Administer the medication piggybacked into a primary IV line using a pump. Explanation: 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 client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Explanation: The timing of administration of opioids in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, opioids are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?

Ambulate only with assistance from the nurse or caregiver. Explanation: The client may have decreased sensory ability from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?

Assess and reposition the woman. Explanation: Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

Clear to straw-colored fluid Explanation: The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

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

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Continue to massage the client's fundus. Explanation: The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment Explanation: The nurse should continue with the assessment to establish a baseline for the client and determine her status. This could include asking any personal questions that might be inappropriate to ask in front of the doula. Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A doula does not take the place of a nurse or client's partner but is there to assist in the process. There would be no need to print off any instructions for the doula to sign.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?

Explanation: General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR Explanation: When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

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.

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 admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

Fetal status Explanation: The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately. If birth is not imminent and the fetal and maternal conditions are stable, perform additional data collection, including the full admission health history, a complete maternal physical assessment, the status of labor and any labor, birth, and cultural preferences the woman may have.

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction. Explanation: The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions. Explanation: First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.

A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?

Inspect the perineum. Explanation: The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, she can then assess the heart sounds, contraction rate, and contact the primary care provider—if there is time.

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 to rotate the fetus in a posterior position. Explanation: 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.

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.

Oxytocin Progesterone Prostaglandins Explanation: 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.

A client is in active labor. As one of the nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder," what would be appropriate for the nurse to do in order to achieve the goal of "no complications due to a full bladder"?

Palpate the area above the symphysis pubis every 2 hours. Explanation: A source of trauma that can interfere with the progress of labor is a full bladder. Every two hours the nurse should palpate the area just above the symphysis pubis feeling for a rounded area of distention, which indicates the bladder is full. This assessment must precede any proposed catheterization. Fluid limitation is unsafe. Providing a bed pan rather than the toilet does not reduce the client's risk.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

Palpate the mother's radial pulse at the same time. Explanation: To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Select all that apply.

Perineal pain Hemorrhoidal discomfort Iron supplements Explanation: After delivery, many women experience a great deal of perineal pain, as well as hemorrhoidal pain, which leads to constipation because the woman is reluctant to defecate, fearing pain. Additionally, iron supplements contribute to constipation also.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?

Practicing effleurage on the abdomen Explanation: In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

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?

The cervix takes around 12 to 16 hours to dilate during first pregnancy. Explanation: 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.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications. Explanation: Administration of pharmacologic agents such as narcotics too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?

Wear a tight, supportive bra. Explanation: The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

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 woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?

You might try using a water-soluble lubricant to ease the discomfort." Explanation: Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased. Explanation: Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

Which feature would alert the nurse that the client is in the transition phase of labor?

beginning urge to bear down Explanation: 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.

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 Explanation: 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.

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 describing to a group of young parents the many changes that will occur during the early postpartum period. The nurse reviews common reports experienced as the woman's body returns to her prepregnancy state. The nurse determines that the teaching was successful when the participants identify which report as being most common during the first week (indicating that fluid volume is returning to normal)?

diaphoresis Explanation: The profuse diaphoresis is common during the early postpartum period. Many women will wake up drenched with perspiration. This diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It is common, especially at night during the first week after birth. Nocturia, urinary frequency, or urinary urgency are not associated with this fluid shift.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis Explanation: Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.

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. 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.

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the fetal heart rate (FHR) by Doppler at which frequency?

every 10 minutes Explanation: During the second stage of labor, the nurse should assess the fetal heart rate (FHR) every 5 to 15 minutes by Doppler or continuously by electronic fetal monitor (EFM).

A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?

fetal back Explanation: The nurse assessing the client should first determine the fetal back before placing the fetoscope on the client's abdomen. The fetal back is determined first because it is through the back that the heart signals are best transmitted. During labor, the fetal heart rate should be assessed to check for any variations indicating distress. Fetal heart rate is auscultated by placing a fetoscope on the client's abdomen in the area of the fetal back. Determining the fetal head, shoulders, and buttocks would be of no help in localizing the heart sounds.

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, active Explanation: 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 (dilatation) 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. The 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 (dilatation) of 0 to 4 cm. The third stage of labor is from birth of the infant to completed delivery of the placenta.

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. Explanation: 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.

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: For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic exam has revealed she is fully dilated. Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen, squatting, or on all fours rather than lying flat to allow gravity to aid the effort .Make sure the woman pushes with contractions and rests between them. She can use short pushes or long, sustained ones, whichever feels more comfortable. 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. To prevent her from holding her breath during pushing, urge her to grunt or breathe out during a pushing effort (as tennis players do).

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 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.

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increased white blood cell count Explanation: 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 explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply.

involution of the uterus contraction of the cervix decrease of pregnancy hormones return of blood volume to prepregnancy level Retrogressive changes represent a return to prepregnancy conditions and include involution of the uterus, contraction of the cervix, decrease of pregnancy hormones, and return of the blood volume to prepregnancy level. Progressive changes involve changes to new processes or roles, such as the formation of breast milk (lactation) and the beginning of a parental role.

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels Explanation: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

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 2 she may remain positive, but the work of labor is very intense.

The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant. Explanation: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia Explanation: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

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?

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.

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?

postpartum depression Explanation: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression Explanation: Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?

rupture of membranes Explanation: The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

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.

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.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?

the taking-hold phase Explanation: The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?

"The injection is given in the space outside the spinal cord." Explanation: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.

Which statement is true regarding analgesia versus anesthesia?

Analgesia and anesthesia perform the same function when it comes to blocking pain. Explanation: Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate. Explanation: After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority

During which time is the nurse correct to document the end of the third stage of labor?

At the time of placental delivery Explanation: 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.

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?

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.

Which cardinal movement of delivery is the nurse correct to document by station?

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.

The nurse will be performing the Leopold maneuver to determine the position of the fetus. List in order the steps that the nurse would take. All options must be used.

Determine presentation. Determine position. Confirm presentation. Determine attitude. Explanation: Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. With the woman in the supine position, perform the first maneuver to determine presentation. The second maneuver determines position. The third maneuver will confirm presentation. The fourth maneuver is performed to determine the attitude of the fetus.

The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

Involution Explanation: Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

Which is identified as the primary outcome for initiating comfort measures during the labor process?

Maintain the labor process Explanation: All of the outcomes are accurate but the primary outcome is to maintain the labor process. By relaxing the mother, it is easier for her to work with her body and facilitate the labor process.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?

Neonatal depression is possible. Explanation: General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. Explanation: The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate Explanation: Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?

endorphins Explanation: The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations Explanation: Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?

touching Explanation: Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.