prepU ch 13 labor and birth process

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."

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign?

"The presenting part is at the true pelvis and is engaged."

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?

8 to 10 cm

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

Allowing the woman time to be alone

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.

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

Fetal heart rate in relation to contractions

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?

Fetal lie

Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready

Which is the most important nursing assessment of the mother during the fourth stage of labor?

Hemorrhage

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Long axis of fetus is perpendicular to that of client.

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

Molding

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?

Radiates from the back to the front

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.

The nurse is caring for four clients within the labor and delivery unit. Which client does the nurse anticipate will be sent home?

The primigravida who has a thinning cervix and a dilation of 3 cm

A nurse is admitting a client who presents in active labor at 41 weeks' gestation. The nurse prepares for the possibility of a cesarean delivery after noting the client has which type of pelvis documented?

android

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?

cervical ripening and softening

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document?

completion of the third stage of labor

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

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

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

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?

increase even if relaxing and taking a shower

A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared?

need for someone to control the situation

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

the buttocks are presenting first with both legs extended up toward the face.

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

to constrict the uterine blood vessels

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?

"I feel pressure in my vagina when I have the contraction."

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is:

"It is rounded in shape and allows ample room for the neonate to fit through the passageway."

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?

shoulder

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?

a cephalohematoma

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 respiratory rate increase in heart rate increase in blood pressure

A pregnant woman at 37 weeks' gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:

occurring about every 5 minutes

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

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

-2

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?

Positive reinforcement

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.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

The frequency of the contractions is every 5 minutes

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.

A nurse is monitoring a woman in labor. Which assessment finding is most concerning to the nurse?

increase in temperature

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

lie

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

lightening

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

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 or stretching of the cervix

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?

relaxin

A nurse is caring for a pregnant client at her 34-week checkup. The client has chosen the Lamaze method for her birthing plan but states that her partner does not agree. The client says she will just change her plan. Which response by the nurse would be appropriate to support the female client?

"Have you and your partner discussed what his/her role will be in the birth?"