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

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

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

B. -2

A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? A. "This is not normal unless you are in active labor; come to the hospital and be checked." B. "That is something we expect with a second or third baby, but because it is your first, you need to be checked." C. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." D. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."

C. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? A. Maternal request for pain medication B. The station in which the fetus is located C. Maternal heart rate and BP D. FHR in relation to contractions

D. FHR in relation to 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? A. Reduction in length of the cervical canal B. Shortening of the upper uterine segment C. Effacement and dilation (dilatation) of the cervix D. Restoration of blood flow to uterus and placenta

D. Restoration of blood flow to uterus and placenta

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? A. 8-10 B. 3-4 C. 5-7 D. 0-2

A. 8-10

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? A. it helps rotate the fetus in a posterior position B. it helps the woman in labor to save energy C. it facilitates external belt adjustment D. it facilitates vaginal examinations

A. it helps rotate the fetus in a posterior position

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? A. lying on side, arms grasped on abdomen B. lying supine with legs in lithotomy stirrups C. head elevated, grasping knees, breathing out D. squatting while holding her breath

C. head elevated, grasping knees, breathing out

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? A. oxytocin B. progesterone C. prolactin D. relaxin

D. relaxin

During the fourth stage of labor, which mother typically experiences the strongest afterpains? A. a multipara who is breastfeeding B. the primigravida who delivers a 6 lb (2,688 g) newborn C. A primigravida whose breastmilk has not come in yet D. a multigravida with twins who decided to formula feed

A. a multipara who is breastfeeding

Which change in client status suggests that labor is anticipated? A. the woman can breathe easier throughout the day B. the woman does not have to urinate as often C. uterine contractions occur but diminish when resting D. the woman is anxious about the birth process

A. the woman can breathe easier throughout the day

The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately? A. acme B. relaxation C. increment D. decrement

B. relaxation

The nurse is monitoring a pregnant 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? A. active B. second C. third D. latent

B. second

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? A. increased risk of breech presentation B. increased risk of infection C. potential rapid birth of fetus D. potential placenta previa

B. increased risk of infection

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

+4

A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? A. Ask the woman to describe why she believes that she is in labor. B. Tell the woman to stay home until her membranes rupture. C. Emphasize that food and fluid should stop or be light. D. Arrange for the woman to come to the hospital for labor evaluation.

A. Ask the woman to describe why she believes that she is in labor.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A. brow B. buttocks C. occiput D. shoulders

C. occiput

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

C. progressive cervical dilation (dilatation) and effacement

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? A. the fetus is floating high in the pelvis B. the client is fully effaced C. the fetus is in the true pelvis and engaged D. the fetus has descended down the birth canal

C. the fetus is in the true pelvis and engaged

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? A. "I will have a strong one and then the next one will be weaker." B. "I feel the tightening primarily in the front of my belly." C. "The contractions lessen after I drink a large glass of water." D. "I feel pressure in my vagina when I have the contraction."

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

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? A. "It thins to let your baby change positions during labor." B. "Your cervix thins so that your contractions can increase." C. "Cervical thinning is a sign that you are in true labor." D. "You need the cervix to thin so it can stretch more easily."

D. "You need the cervix to thin so it can stretch more easily."

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? A. occiput B. acromion process C. chin D. buttocks

D. buttocks

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? A. increased blood glucose levels B. increased WBC count C. decreased plasma fibrinogen levels D. Increased blood coagulation time

B. increased WBC count

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

B. passageway, passenger, position, powers, psych.

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? A. lasts about 20-25 seconds B. radiates from the front to the back C. slows when the woman changes position D. occurs in an irregular pattern

B. radiates from the front to the back

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: A. Occurring about every 5 minutes B. Occurring in the abdomen and groin C. Relieved by walking D. Lasting about 30 seconds

A. Occurring about every 5 minutes

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

C. At the time of placental delivery

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? A. prepare the client for cesarean birth of the fetus B. continue to monitor the progress of labor C. auscultate fetal heart rate in the LUQ D. educate the client this fetal position may result in a longer labor

B. continue to monitor the progress of labor

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? A. ROA B. LOP C. ROP D. LOA

A. ROA

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. A. increase in gastric emptying and pH B. increase in RR C. slight decrease in body temperature D. increase in HR E. increase in BP

B. increase in RR D. increase in HR E. increase in BP

A nurse is monitoring a woman in labor. Which assessment finding is most concerning to the nurse? A. BP 128/82 B. RR 22/min C. Temp 101.6 D. Client begins vomiting

C. Temp 101.6

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? A. The contraction pains are 2 minutes apart and 1 minute in duration. B. The contraction pains have been present for 5 hours, and the patterns are regular. C. After walking for an hour, the contractions have not fully subsided. D. The client reports back pain, and the cervix is effacing and dilating.

D. The client reports back pain, and the cervix is effacing and dilating.

Which cardinal movement of delivery is the nurse correct to document by station? A. internal rotation B. extension C. flexion D. descent

D. descent

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? A. these contractions increase oxytocin sensitivity B. these contractions make maternal breathing easier C. these contractions increase the release of prostaglandins D. these contractions help in softening and ripening the cervix.

D. these contractions help in softening and ripening the cervix.

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? A. stage three B. latent C. active D. stage two

B. latent