Chapter 12: Processes of Birth My Nursing Test Banks

Chapter 12: Processes of Birth

MULTIPLE CHOICE

1. The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that hes doing now, he could tell her when the contractions are:

a.

2 minutes apart.

b.

at their acme.

c.

at their increment.

d.

at their decrement.

ANS: B

When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity.

PTS: 1 DIF: Cognitive Level: Understanding REF: 196, 197

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction?

a.

Is not significantly affected

b.

Increases as blood pressure decreases

c.

Diminishes as the spiral arteries are compressed

d.

Continues except when placental functions are reduced

ANS: C

During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

PTS: 1 DIF: Cognitive Level: Application REF: 199

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

3. The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions?

a.

Vital signs taken during contractions are not accurate.

b.

During a contraction, assessing fetal heart rate is the priority.

c.

Maternal blood flow to the heart is reduced during contractions.

d.

Maternal circulating blood volume increases temporarily during contractions.

ANS: D

During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

PTS: 1 DIF: Cognitive Level: Application REF: 198

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

4. Uncontrolled maternal hyperventilation during labor results in:

a.

metabolic acidosis.

b.

metabolic alkalosis.

c.

respiratory acidosis.

d.

respiratory alkalosis.

ANS: D

Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

PTS: 1 DIF: Cognitive Level: Understanding REF: 198

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

5. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?

a.

Extension

b.

Engagement

c.

Internal rotation

d.

External rotation

ANS: B

Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

PTS: 1 DIF: Cognitive Level: Understanding REF: 209

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by:

a.

promoting blood flow to the cervix.

b.

contracting the lower uterine segment.

c.

enlarging the internal size of the uterus.

d.

pulling the cervix over the fetus and amniotic sac.

ANS: D

Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

PTS: 1 DIF: Cognitive Level: Application REF: 198

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

7. Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have:

a.

a higher hematocrit.

b.

increased leukocytes.

c.

increased blood volume.

d.

a lower fibrinogen level.

ANS: C

Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 198

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions?

a.

Assess the strongest intensity of each contraction.

b.

Assess uterine relaxation between two contractions.

c.

Assess from the beginning to the end of each contraction.

d.

Assess from the beginning of one contraction to the beginning of the next.

ANS: C

Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

PTS: 1 DIF: Cognitive Level: Application REF: 196, 197

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

9. Which event is the best indicator of true labor?

a.

Bloody show

b.

Cervical dilation and effacement

c.

Fetal descent into the pelvic inlet

d.

Uterine contractions every 7 minutes

ANS: B

The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

PTS: 1 DIF: Cognitive Level: Understanding REF: 198

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

10. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?

a.

Station

b.

Flexion

c.

Descent

d.

Engagement

ANS: B

The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet.

PTS: 1 DIF: Cognitive Level: Understanding REF: 209

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates:

a.

lightening.

b.

breech presentation.

c.

urinary tract infection.

d.

onset of Braxton-Hicks contractions.

ANS: A

As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 207

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long?

a.

50 minutes

b.

hours

c.

6 to 7 hours

d.

8 to 10 hours

ANS: D

The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 minutes for a nullipara. The transition phase lasts hours for a nullipara. A multiparas active phase of labor is 6 to 7 hours.

PTS: 1 DIF: Cognitive Level: Analysis REF: 208

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

13. A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client?

a.

This results from molding.

b.

This results from lightening.

c.

This results from the fetal lie.

d.

This results from the fetal presentation.

ANS: A

The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

PTS: 1 DIF: Cognitive Level: Application REF: 201

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

14. A client whose cervix is dilated to 5 cm is considered to be in which phase of labor?

a.

Latent phase

b.

Active phase

c.

Second stage

d.

Third stage

ANS: B

The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

PTS: 1 DIF: Cognitive Level: Understanding REF: 212

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase?

a.

The client is sociable and excited.

b.

The client is requesting pain medication.

c.

The client begins to experience the urge to push.

d.

The client experiences loss of control and irritability.

ANS: B

During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

PTS: 1 DIF: Cognitive Level: Application REF: 212

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

16. A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?

a.

The acme

b.

The interval

c.

The increment

d.

The decrement

ANS: A

The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.

PTS: 1 DIF: Cognitive Level: Application REF: 196, 197

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

17. A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with:

a.

more rapid labor.

b.

a high risk of infection.

c.

maternal perineal trauma.

d.

umbilical cord compression.

ANS: D

The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 202, 203

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. The primary difference between the labor of a nullipara and that of a multipara is:

a.

total duration of labor.

b.

level of pain experienced.

c.

amount of cervical dilation.

d.

sequence of labor mechanisms.

ANS: A

Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors.

PTS: 1 DIF: Cognitive Level: Analysis REF: 214

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

19. Which maternal factor may inhibit fetal descent?

a.

A full bladder

b.

Decreased peristalsis

c.

Rupture of membranes

d.

Reduction in internal uterine size

ANS: A

A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

PTS: 1 DIF: Cognitive Level: Understanding REF: 198

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

20. Which assessment finding would cause a concern for a client who had delivered vaginally?

a.

Estimated blood loss (EBL) of 500 mL during the birth process

b.

White blood cell count of 28,000 mm3 postbirth

c.

Client complains of fingers tingling

d.

Client complains of thirst

ANS: C

A clients complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels.

PTS: 1 DIF: Cognitive Level: Application REF: 198

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

21. Which clinical findings would be considered to be normal for a preterm fetus during the labor period?

a.

Baseline tachycardia

b.

Baseline bradycardia

c.

Fetal anemia

d.

Acidosis

ANS: A

Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

PTS: 1 DIF: Cognitive Level: Application REF: 199

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

22. On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?

a.

Perform a vaginal exam to denote progress.

b.

Notify the health care provider.

c.

Initiate parenteral therapy.

d.

Apply oxygen via nasal cannula at 8 L/min.

ANS: B

A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.

PTS: 1 DIF: Cognitive Level: Analysis REF: 202

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

23. An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is:

a.

onset of irregular contractions.

b.

cephalic presentation at 0 station.

c.

bloody mucus drainage from vagina.

d.

fetal heart tones (FHTs) present in the lower right quadrant.

ANS: C

Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening.

PTS: 1 DIF: Cognitive Level: Analysis REF: 207

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

24. If a notation on the clients health record states that the fetal position is LSP, this means that the:

a.

head is in the right posterior quadrant of the pelvis.

b.

head is in the left anterior quadrant of the pelvis.

c.

buttocks are in the left posterior quadrant of the pelvis.

d.

buttocks are in the right upper quadrant of the abdomen.

ANS: C

LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT.

PTS: 1 DIF: Cognitive Level: Analysis REF: 204

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

25. The assessment finding which indicates that the client is in the active phase of the first stage of labor is:

a.

80% effacement.

b.

dilation of 5 cm.

c.

presence of bloody show.

d.

regular contraction every 3 to 4 minutes.

ANS: B

The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined.

PTS: 1 DIF: Cognitive Level: Analysis REF: 212

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

26. To determine if the client is in true labor, the nurse would assess for changes in:

a.

cervical dilation.

b.

amount of bloody show.

c.

fetal position and station.

d.

pattern of uterine contractions.

ANS: A

Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 208

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

27. The health care provider for a laboring patient makes the following entry into the patients record: 3/50%/1. What instruction will the nurse implement with the patient?

a.

You will need to remain in bed attached to the electronic fetal monitor.

b.

Breathe with me slowly, in through your nose and out through your mouth.

c.

I will begin the administration of 1000 mL of IV fluid so you can have an epidural.

d.

Your partner will need to change into scrub attire to attend the imminent birth.

ANS: B

This client is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the stem that the membranes are ruptured, which may prohibit the patient from ambulating. Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at 1 station. Epidural placement during early labor may slow down the labor process. There is no indication that birth is imminent because the patient is 3 cm dilated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 212

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

28. The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient?

a.

On her back

b.

On her left side

c.

On her right side

d.

On her hands and knees

ANS: B

LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus. Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are present, there is no need to implement this position.

PTS: 1 DIF: Cognitive Level: Analysis REF: 204

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

29.

The primipara at 39 weeks gestation states to the nurse, I can breathe easier now. What is the nurses best response?

a.

You labor will start any day now since the baby has dropped.

b.

That process is called lightening. Do you have to urinate more frequently?

c.

Contact your health care provider when your contractions are every 5 minutes for 1 hour.

d.

You will likely not feel you babys movements as much now, so do not be concerned.

ANS: B

As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patients statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

PTS: 1 DIF: Cognitive Level: Application REF: 207

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

30. The nurse assess a laboring patients contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern?

a.

Stage 1, latent phase

b.

Stage 2, latent phase

c.

Stage 1, active phase

d.

Stage 2, active phase

ANS: C

In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage 2, latent phase, the woman is resting and preparing to push; she likely has not experienced the Ferguson reflex. She is actively bearing down during the active phase of the second stage.

PTS: 1 DIF: Cognitive Level: Understanding REF: 212

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

31. A laboring patient states to the nurse, I have to push! What is the next nursing action?

a.

Contact the health care provider.

b.

Examine the patients cervix for dilation.

c.

Review with her how to bear down with contractions.

d.

Ask her partner to support her head with each push.

ANS: B

When the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed.

PTS: 1 DIF: Cognitive Level: Application REF: 199

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

32. After birth of the placenta the patient states, All of a sudden I feel very cold. What is the best nursing action in response to this statement?

a.

Place a warm blanket over the patient.

b.

Place the baby on the patients abdomen.

c.

Tell the patient that chills are expected after birth.

d.

What do you mean by your words very cold?

ANS: A

Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary.

PTS: 1 DIF: Cognitive Level: Application REF: 214

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

33. A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.)

a.

Ask her if her if she thinks that her membranes have ruptured.

b.

Ask her if she has any evidence of bloody show.

c.

Have her keep monitoring her contraction pattern and call you back if they become more regular.

d.

Ask her when her she has her next scheduled visit with her health care provider.

e.

Tell her to come into the hospital for evaluation.

ANS: A, E

The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 208

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

34. A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.)

a.

In true labor, the cervix begins to dilate.

b.

In true labor, the contractions are felt in the abdomen and groin.

c.

In true labor, contractions often resemble menstrual cramps during early labor.

d.

In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.

e.

In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

ANS: A, C, E

In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking. False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in frequency, duration, and intensity.

PTS: 1 DIF: Cognitive Level: Application REF: 208

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

35. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)

a.

Powers

b.

Passage

c.

Position

d.

Passenger

e.

Psyche

ANS: A, B, D, E

Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis.

Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor.

Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger.

Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the womans ability to cope.

Position is not one of the four Ps.

PTS: 1 DIF: Cognitive Level: Analysis REF: 199

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

36. The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)

a.

Offer the client a warm blanket.

b.

Place an ice pack on the perineum.

c.

Massage the uterus if it is boggy.

d.

Delay breastfeeding until the client is rested.

e.

Explain to the client that the lochia will be light pink in color.

ANS: A, B, C

The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

PTS: 1 DIF: Cognitive Level: Application REF: 214

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

37. Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)

a.

A gush of blood appears.

b.

The uterus rises upward in the abdomen.

c.

The fundus descends below the umbilicus.

d.

The cord descends further from the vagina.

e.

The uterus becomes boggy and soft, with an elongated shape.

ANS: A, B, D

Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected.

PTS: 1 DIF: Cognitive Level: Analysis REF: 214

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

38. The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.)

a.

Progesterone levels become higher than estrogen levels.

b.

Natural oxytocin in conjunction with other substances plays a role.

c.

Stretching, pressure, and irritation of the uterus and cervix increase.

d.

The secretion of prostaglandins from the fetal membranes decreases.

ANS: B, C

Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labors initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

PTS: 1 DIF: Cognitive Level: Application REF: 207

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

MATCHING

Match each term with the correct definition.

a.

The fetal part that enters the pelvic inlet first

b.

The orientation of the long axis of the fetus to the long axis of the woman

c.

Relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis

39. Position

40. Fetal lie

41. Presentation

39. ANS: C PTS: 1 DIF: Cognitive Level: Understanding

REF: 201 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The position is the relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis. The fetal lie is the orientation of the long axis of the fetus to the long axis of the woman. The presentation is the fetal part that enters the pelvic inlet first.

40. ANS: B PTS: 1 DIF: Cognitive Level: Understanding

REF: 202 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The position is the relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis. The fetal lie is the orientation of the long axis of the fetus to the long axis of the woman. The presentation is the fetal part that enters the pelvic inlet first.

41. ANS: A PTS: 1 DIF: Cognitive Level: Understanding

REF: 202 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The position is the relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis. The fetal lie is the orientation of the long axis of the fetus to the long axis of the woman. The presentation is the fetal part that enters the pelvic inlet first.

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