the labor suite for assessment.

However,
1. A client enters the labor and delivery suite the only assessment that will determine
stating that she thinks she is in labor. whether or not a woman is in true
Which of the following information about the labor is a vaginal examination. Only
woman should the nurse note from when there is cervical change—dilation
the woman’s prenatal record before and/or effacement—is it determined that
proceeding with the physical assessment? a woman is in true labor
Select all that apply. 3
1. Weight gain. A client in labor, G2 P1001, was admitted 1
2. Ethnicity and religion. hour ago at 2 cm dilated and 50%
3. Age effaced. She was talkative and excited at
.
4. Type of insurance. that time. During the past 10 minutes she
5. Gravidity and parity. has become serious, closing her eyes and
breathing rapidly with each contraction.
Which of the following is an accurate nursing
1. 1, 2, 3, and 5 are correct. assessment of the situation?
1. Before proceeding with a physical 1. The client had poor childbirth education
assessment, prior to labor.
the nurse should check the 2. The client is exhibiting an expected
client’s weight gain reported in her behavior for labor.
prenatal record. 3. The client is becoming hypoxic and
2. The client’s ethnicity and religion hypercapnic.
should be noted before physical assessment. 4. The client needs her alpha-fetoprotein
This allows the nurse to proceed levels checked.
in a culturally sensitive manner.
3. The client’s age should also be noted
before the physical assessment is 2. The woman is showing expected signs
begun. of the active phase of labor.

5. The client’s gravidity and parity—how TEST-TAKING TIP: The test taker must be
many times she has been pregnant familiar with the different phases of the
and how many times she has given first stage of labor: latent, active, and
birth—should also be noted before a transition. The multiparous woman in the
physical assessment is begun. scenario entered the labor suite in the latent
TEST-TAKING TIP: The prenatal record is a phase of labor when being talkative
summary of the woman’s history from and excited is normal, but after 1 hour
the time she entered prenatal care until she has progressed into the active phase
the record was sent to the labor room of labor in which being serious and
(usually at about 36 weeks’ gestation). breathing rapidly with contractions is
Virtually all of the physical and psychosocial expected
information relating to this behavior.
woman is pertinent to the care by the 4
nurse. For example, if a woman has A woman has just arrived at the labor and
gained very little weight during her delivery suite. In order to report the
pregnancy, client’s status to her primary health care
the baby may be small-forgestational practitioner, which of the following
age. The nurse may also have assessments
to change his or her care in relation to should the nurse perform? Select all that
the woman’s ethnicity and religion, etc. apply.
2 1. Fetal heart rate.
A woman who states that she “thinks” she is 2. Contraction pattern.
in labor enters the labor suite. Which 3. Contraction stress test.
of the following assessments will provide the 4. Vital signs.
nurse with the most valuable information 5. Biophysical profile.
regarding the client’s labor status? 4. 1, 2, and 4 are correct.
1. Leopold’s maneuvers. 1. The nurse should assess the fetal
2. Fundal contractility. heart before reporting the client’s
3. Fetal heart assessment. status to the health care provider.
4. Vaginal examination. 2. The nurse should assess the contraction
pattern before reporting the
4. A vaginal examination will provide the client’s status.
nurse with the best information about
the status of labor. 4. The nurse should assess the woman’s
TEST-TAKING TIP: Each of the assessments vital signs before reporting her status.
listed is performed on a woman who enters
TEST-TAKING TIP: The fetal heart, contraction
pattern, and maternal vitals all at the end of a contraction.
should be assessed in order to provide
the health care practitioner with a picture 5. The nurse should assess the fetal
of the health status of the mother heart before the woman ambulates.
and fetus. In some institutions, the nurse TEST-TAKING TIP: Except for invasive
may also do a vaginal examination to assess procedures,
for cervical change. assessment of the fetal heart
pattern is the only way to evaluate the
5 well-being of a fetus during labor. The
5. While performing Leopold’s maneuvers on fetal heart pattern should, therefore, be
a woman in labor, the nurse palpates a assessed whenever there is a potential for
hard round mass in the fundal area, a flat injury to the baby or to the umbilical
surface on the left side, small objects on cord. At each of the times noted in the
the right side, and a soft round mass just scenario—vaginal exam, analgesic
above the symphysis. Which of the following administration,
is a reasonable conclusion by the nurs e? contraction, and ambulation—
1. The fetal position is transverse. either the cord could be compressed or
2. The fetal presentation is vertex. the baby could be compromised.
3. The fetal lie is vertical.
4. The fetal attitude is flexed. 7
7. The nurse is assessing the fetal station
during a vaginal examination. Which of the
3. With the findings of a hard round following structures should the nurse
mass in the fundal area and soft palpate?
round mass above the symphysis, the 1. Sacral promontory.
nurse can conclude that the fetal lie is 2. Ischial spines.
vertical. 3. Cervix.
4. Symphysis pubis.
TEST-TAKING TIP: Many obstetric
assessments
have a component that is sensual 2. Station is assessed by palpating the
and a component that is an interpretation ischial spines.
or concept. Leopold’s maneuvers are
good examples. The nurse palpates specific TEST-TAKING TIP: The test taker must be
areas of the pregnant abdomen, but thoroughly familiar with the anatomy of
then must interpret or translate what he the female reproductive system and the
or she is feeling into a concept. For measurements taken during pregnancy
example, in the scenario presented, the and labor. Station is determined by creating
nurse palpates a hard, round mass in the an imaginary line between the ischial
fundal area of the uterus and must interpret spines. The descent of the presenting
that feeling as the fetal head. Similarly part of the fetus is then compared with
the nurse palpates a soft round mass the level of that “line.”
above the symphysis and must interpret
that feeling as the fetal buttocks. With 8
these findings and interpretations, the 8. The labor and delivery nurse performs
nurse will then realize that the fetal lie is Leopold’s maneuvers. A soft round mass is
vertical. felt in the fundal region. A flat object is noted
on the left and small objects are
6 noted on the right of the uterus. A hard
6. When during the latent phase of labor round mass is noted above the symphysis.
should the nurse assess the fetal heart Which of the following positions is consistent
pattern of a low-risk woman, G1 P0000? with these findings?
Select all that apply. 1. Left occipital anterior (LOA)
1. After vaginal exams. 2. Left sacral posterior (LSP)
2. Before administration of analgesics. 3. Right mentum anterior (RMA)
3. Periodically at the end of a 4. Right sacral posterior (RSP)
contraction.
4. Every ten minutes. 8. 1. The nurse’s findings upon performing
5. Before ambulating. Leopold’s maneuvers indicate that the
fetus is in the left occiput anterior position
6. 1, 2, 3, and 5 are correct. (LOA)—that is, the fetal back is
1. The nurse should assess the fetal felt on the mother’s left side, the
heart after all vaginal exams. small parts are felt on her right side,
2. The nurse should assess the fetal the buttocks are felt in the fundal region,
heart before giving the mother any and the head is felt above her
analgesics. symphysis.
3. The fetal heart should be assessed
periodically
TEST-TAKING TIP: The test taker must at 1 station are 1 cm above the
review fetal positioning. This is an especially ischial spines.
difficult concept to understand. The best way
to learn the threedimensional
concept of fetal position TEST-TAKING TIP: If the test taker
is to look at the pictures in a text and understands
then to get a doll and to imitate the the definition of station, he or she
pictures by placing the doll into each could easily eliminate two of the four
of the positions. responses
9 in this question. When the presenting
9. A nurse is caring for a laboring woman part of the fetus is at zero (0)
who is in transition. Which of the following station, the part is at the same level as an
signs/symptoms would indicate that the imaginary line between the mother’s ischial
woman is progressing into the second stage spines. When the presenting part is
of labor? Select all that apply. above the spines, the station is negative
1. Bulging perineum. (). When the presenting part has
2. Increased bloody show. moved past the spines, the station is defined
3. Spontaneous rupture of the membranes. as positive (). Since the question
4. Uncontrollable urge to push. states that the nurse palpated the buttocks
5. Inability to breathe through contractions. above the spines, the station is
negative. This effectively eliminates the
9. 1, 2, and 4 are correct. As the fetal two answer options that include a positive
head descends through a fully dilated station.
cervix, the perineum begins to bulge,
the bloody show increases, and the 11
laboring woman usually feels a strong 11. The nurse enters a laboring client’s room.
urge to push. The client is complaining of intense back
1. A bulging perineum indicates progression pain with each contraction. The nurse
to the second stage of labor. concludes that the fetus is likely in which of
2. The bloody show increases as a the following positions?
woman enters the second stage of 1. Mentum anterior.
labor 2. Sacrum posterior.
3. Occiput posterior.
4. With a fully dilated cervix and bulging 4. Scapula anterior.
perineum, laboring women usually
feel a strong urge to push. 3. When a fetus is in the occiput posterior
position, mothers frequently
complain of severe back pain.
TEST-TAKING TIP: It is important that the
test taker clearly understands the difference
between the three phases of the first TEST-TAKING TIP: If the test taker were to
stage of labor and the three stages of view a picture of a baby in the occiput
labor. The three phases of the first stage posterior position, he or she would note
of labor—latent, active, and transition— that the occiput of the baby lies adjacent
are related to changes in cervical dilation to the coccyx of the mother. During each
and maternal behaviors. The three stages contraction, the occiput, therefore, is
of labor are defined by specific labor forced backward into the coccyx. This
progressions— action is very painful.
cervical change to full dilation 12
(stage 1), full dilation to birth of the baby 12. When performing Leopold’s maneuvers,
(stage 2), birth of the baby to birth of the the nurse notes that the fetus is in the left
placenta (stage 3). occiput anterior position. Where should the
10 nurse place a fetoscope best to hear
10. During a vaginal examination, the nurse the fetal heart beat?
palpates fetal buttocks that are facing the 1. Left upper quadrant.
left posterior and are 1 cm above the ischial 2. Right upper quadrant.
spines. Which of the following is 3. Left lower quadrant.
consistent with this assessment? 4. Right lower quadrant.
1. LOA 1 station. 3. The fetoscope should be placed in
2. LSP 1 station. the left lower quadrant for a fetus
3. LMP 1 station. positioned in the LOA position as
4. LSA 1 station. described in the question
2. The LSP position is the correct
answer. The fetal buttocks (S or
sacrum) are facing toward the TEST-TAKING TIP: The fetal heart is best
mother’s left posterior (LP) and buttocks heard through the fetal back. Since, as
determined by doing Leopold’s maneuvers choice 4 meets all criteria set forth in
the baby is LOA, the fetal back (and, the question.
hence, the fetal heart) is in the left lower
quadrant. 15
15. The nurse is caring for a nulliparous
13 client who attended Lamaze childbirth
13. On examination, it is noted that a full- education
term primipara in active labor is right classes. Which of the following techniques
occipitoanterior should the nurse include in her plan
(ROA), 7 cm dilated, and 3 station. Which of of care? Select all that apply.
the following should the 1. Hypnotic suggestion.
nurse report to the physician? 2. Rhythmic chanting.
1. Descent is progressing well. 3. Muscle relaxation.
2. Fetal head is not yet engaged. 4. Pelvic rocking.
3. Vaginal delivery is imminent. 5. Abdominal massage.
4. External rotation is complete
3, 4, and 5 are correct
1. Descent is progressing well. The
presenting
part is 3 centimeters below 3. Muscle relaxation is an integral part
the ischial spines of Lamaze childbirth education.
4. Pelvic rocking is taught in Lamaze
classes as a way of easing back pain
TEST-TAKING TIP: This question includes during pregnancy and labor.
a number of concepts. Descent and station 5. Abdominal massage, called effleurage,
are discussed in answer options is also an integral part of Lamaze
1 and 2. The dilation of the cervix, which childbirth education.
is related to the fact that the woman is a TEST-TAKING TIP: The test taker may
primigravida, is discussed in choice have expected to find breathing
3. And, one of the cardinal moves of techniques included in the question
labor—external rotation—is included in related to Lamaze childbirth education.
choice 4. The test taker must be prepared Although breathing techniques are
to answer questions that are complex taught, there are a number of other
and that include diverse information. techniques and principles that couples
In a 7-cm dilated primipara, with a learn in Lamaze classes. The test taker
baby at 3 station, vaginal delivery is not should be familiar with all aspects of
imminent, but the fetal head is well past childbirth education.
engagement and descent is progressing
well. External rotation has not yet occurred 16
since the baby’s head has not yet 16. Which of the following responses is the
been birthed. primary rationale for providing general
information as well as breathing and
14 relaxation exercises in childbirth education
14. One hour ago, a multipara was examined classes?
with the following results: 8 cm, 50% 1. Mothers who are doing breathing
effaced, and 1 station. She is now pushing exercises during labor will refrain from
with contractions and the fetal head is yelling.
seen at the vaginal introitus. The nurse 2. Breathing and relaxation exercises are
concludes that the client is now less exhausting than crying and moaning.
1. 9 cm dilated, 70% effaced, and 2 station. 3. Knowledge learned at childbirth education
2. 9 cm dilated, 80% effaced, and 3 station. classes helps to break the feartension-
3. 10 cm dilated, 90% effaced, and 4 station. pain cycle.
4. 10 cm dilated, 100% effaced, and 5 4. Childbirth education classes help to
station. promote positive maternal-newborn
bonding.
4. The cervix is fully dilated and fully effaced
and the baby is low enough to 3. Some of the techniques learned at
be seen through the vaginal introitus. childbirth education classes are meant
TEST-TAKING TIP: To answer this question, to break the fear-tension-pain cycle.
the test taker must methodically
evaluate each of the given responses. TEST-TAKING TIP: When a frightened
Once the nurse determines that a woman woman enters the labor suite, she is
is not yet fully dilated or effaced, it can likely to be very tense. It is known that
be determined that the woman is still in pain is often worse when tensed muscles
stage 1 of labor. Choice 3 does show a are stressed. Once the woman feels pain,
woman who is fully dilated but who is she may become even more frightened
yet to efface fully and whose baby is and tense. This process becomes a
still above the vaginal introitus. Only vicious cycle. The information and skills
learned at childbirth education classes should the nurse take at this time?
are designed to break the cycle. 1. Assess the blood pressure.
2. Have the woman breathe into a bag.
17 3. Turn the woman onto her side.
17. The childbirth educator is teaching a 4. Check the fetal heart rate.
class of pregnant couples the breathing
technique 2. This client is showing signs of
that is most appropriate during the second hyperventilation. The symptoms will
stage of labor. Which of the following likely subside if she rebreathes her
techniques did the nurse teach the women to exhalations.
do?
1. Alternately pant and blow.
2. Take rhythmic, shallow breaths. TEST-TAKING TIP: It is essential that the
3. Push down with an open glottis. test taker attend to the clues in the
4. Do slow chest breathing. question and not assume that other
3. Open glottal pushing is used during issues may be occurring. This client is
stage 2 of labor. light-headed as a result of being tachypneic
during contractions. This fact is
essential. Hyperventilation, which can result
TEST-TAKING TIP: Because the laboring from tachypnea, is characterized by
client is in stage 2, the woman will tingling and light-headedness. Rebreathing
change from using breathing techniques her air should rectify the problem
during contractions to pushing during
contractions in order to birth the baby. 20
Open glottal pushing is recommended 20. A nurse is teaching a class of pregnant
since pushing against a closed glottis can couples the most therapeutic breathing
decrease the mother’s oxygen saturation technique
for the latent phase of labor. Which of the
18 following techniques did the nurse
18. A nurse is teaching childbirth education teach?
classes to a group of pregnant teens. 1. Alternately panting and blowing.
Which of the following strategies would 2. Rapid, deep breathing.
promote learning by the young women? 3. Grunting and pushing with contractions.
1. Avoiding the discussion of uncomfortable 4. Slow chest breathing.
procedures like vaginal exams and
blood tests. 4. Most women find slow chest breathing
2. Focusing the discussion on baby care effective during the latent phase.
rather than labor and delivery. TEST-TAKING TIP: Because the latent
3. Utilizing visual aids like movies and phase is the first phase of the first stage
posters during the classes. of labor, the contractions are usually
4. Having the classes at a location other than mild and they rarely last longer than
high school to reduce their 30 seconds. A slow chest breathing
embarrassment. technique, therefore, is effective and
does not tire the woman out for the
3. Using visual aids can help to foster remainder
learning in teens as well as adults. of her labor.
21
21. A woman, G2 P0101, 5 cm dilated and
TEST-TAKING TIP: Because of their classroom 30% effaced, is doing first-level Lamaze
experiences, adolescents are accustomed breathing with contractions. The nurse
to learning in groups. The school detects that the woman’s shoulder and face
setting is comfortable for them and, because muscles are beginning to tense during the
of its location and its familiarity, is contractions. Which of the following
an ideal setting for childbirth education interventions
programs. In addition, educators often should the nurse perform first?
use visual aids to promote learning and, 1. Encourage the woman to have an
since teens are frequent theatergoers, epidural.
showing movies is an especially attractive 2. Encourage the woman to accept
way to convey information to them. intravenous analgesia.
19 3. Assist the woman in changing position.
19. A client, who is 7 cm dilated and 100% 4. Urge the woman to perform the next level
effaced, is breathing at a rate of 30 breaths breathing.
per minute during contractions. Immediately 4. This woman is in the active phase
after a contraction, she complains of of labor. The first phase breathing
tingling in her fingers with some is probably no longer effective.
lightheadedness. Which of the following Encouraging her to shift to the next
actions
level of breathing is appropriate at 24. A gravid client, G3 P2002, was examined
this time. 5 minutes ago. Her cervix was 8 cm
TEST-TAKING TIP: If a woman has learned dilated and 90% effaced. She now states that
Lamaze breathing, it is important to support she needs to move her bowels. Which
her actions. Encouraging her to take of the following actions should the nurse
pain-relieving medications may undermine perform first?
her resolve and make her feel like 1. Offer the client the bedpan.
she has failed. The initial response by 2. Evaluate the progress of labor.
the nurse should be to support her by 3. Notify the physician.
encouraging her to use her breathing 4. Encourage the patient to push.
techniques.
2. The nurse should first assess the
22 progress of labor to see if the client
22. In addition to breathing with has moved into the second stage of
contractions, which of the following actions labor.
can help
a woman in labor to work with the pain of the
first stage of labor? TEST-TAKING TIP: The average length of
1. Lying in the lithotomy position. transition in multiparas is 10 minutes.
2. Performing effleurage. This client is likely, therefore, to have
3. Practicing Kegel exercises. moved into the second stage of labor.
4. Pushing with each contraction. The nurse’s first action, therefore, is to
2. Effleurage is a light massage that can assess the progress of labor. If she is in
soothe the mother during labor. second stage, the physician will be notified
and the client will be encouraged to
push. If she is not yet in second stage,
she may need the bedpan.
TEST-TAKING TIP: There are a number of
actions that mothers can take that can 25
support their breathing during labor. 25. The nurse auscultates a fetal heart rate
Walking, swaying, and rocking can all of 152 on a client in early labor. Which of
help a woman during the process. the following actions by the nurse is
Effleurage, the light massaging of the appropriate?
abdomen or thighs, is often soothing for 1. Inform the mother that the rate is normal.
the mothers. 2. Reassess in 5 minutes to verify the results.
3. Immediately report the rate to the health
23 care practitioner.
23. A client is in the second stage of labor. 4. Place the client on her left side and apply
She falls asleep immediately after a oxygen by face mask.
contraction.
Which of the following actions should the 1. This is the correct response. A fetal
nurse perform as a result? heart rate of 152 is normal.
1. Awaken the woman and remind her to
push.
2. Cover the woman’s perineum with a sheet. TEST-TAKING TIP: It is essential that the
3. Assess the woman’s blood pressure and test taker know the normal physiological
pulse. responses of women and their fetuses in
4. Administer oxygen to the woman via face labor. The normal fetal heart rate is 110
mask. to 160 bpm. A rate of 152, therefore, is
2. The woman’s privacy should be within normal limits. No further action is
maintained needed at this time.
while she is resting. 26
26. The nurse documents in a laboring
woman’s chart that the fetal heart is being
TEST-TAKING TIP: Since the woman is in “assessed via intermittent auscultation.” To
second stage, she is pushing with be consistent with this statement, the
contractions. nurse, using a Doppler electrode, should
If she is very tired, she is likely assess the fetal heart at which of the
to fall asleep immediately following a following
contraction. It is important for the nurse times?
to maintain the woman’s privacy by covering 1. After every contraction.
her perineum with a sheet between 2. For 10 minutes every half hour.
contractions. It would also be appropriate 3. Periodically during the peak of
to awaken the woman at the beginning contractions.
of the next contraction. 4. For 1 minute immediately after
contractions.
24
4. Intermittent auscultation should be and return to baseline well after contractions
performed for 1 full minute after contractions are over, and variable decelerations
end. can occur at anytime and are unrelated
TEST-TAKING TIP: Although most babies to contractions.
are monitored via electronic fetal monitoring
in labor, there is a great deal of 29
evidence to show that intermittent 29. A client is complaining of severe back
auscultation is as effective a method of labor. Which of the following nursing
monitoring the fetal heart. It is essential, interventions
however, that the fetal heart be would be most effective?
monitored immediately after contractions 1. Assist mother with childbirth breathing.
for 1 full minute in order to identify 2. Encourage mother to have an epidural.
the presence of any late or variable 3. Provide direct sacral pressure.
decelerations. 4. Use a hydrotherapy tub.

27 3. When direct sacral pressure is

27. While caring for a client in the transition applied, the nurse is providing a
phase of labor, the nurse notes that the counteraction to the pressure being
fetal monitor tracing shows average short- exerted by the fetal head.
term and long-term variability with a
baseline of 142 beats per minute (bpm).
What should the nurse do? TEST-TAKING TIP: Whenever a laboring
1. Provide caring labor support. woman complains of severe back labor, it
2. Administer oxygen via face mask. is very likely that the baby is lying in the
3. Change the client’s position. occiput posterior position. Every time
4. Speed up the client’s intravenous. the woman has a contraction, the head is
pushed into the coccyx. When direct
1. The tracing is showing a normal fetal pressure is applied to the sacral area, the
heart tracing. No intervention is nurse is providing counteraction to the
needed. pressure being exerted by the fetal head.

TEST-TAKING TIP: The baseline fetal heart

variability is the most important fetal
heart assessment that the nurse makes. If 30
the baby’s heart rate shows average 30. An obstetrician is performing an
variability, amniotomy on a gravid woman in transition.
the nurse can assume that the Which of the following assessments must the
baby is not hypoxic or acidotic. In addition, nurse make immediately following
the normal heart rate of 142 is reassuring. the procedure?
1. Maternal blood pressure.
28 2. Maternal pulse.
28. While evaluating the fetal heart monitor 3. Fetal heart rate.
tracing on a client in labor, the nurse 4. Fetal fibronectin level.
notes that there are fetal heart decelerations
present. Which of the following assessments 3. It is essential to assess the fetal heart
must the nurse make at this time? rate immediately after an amniotomy.
1. The relationship between the
decelerations and the labor contractions.
2. The maternal blood pressure. TEST-TAKING TIP: Amniotomy, as the word
3. The gestational age of the fetus. implies, is the artificial rupture of the
4. The placement of the fetal heart electrode amniotic sac. During the procedure,
in relation to the fetal position. there is a risk that the umbilical cord may
become compressed. Because there is no
1. The relationship between the direct way to assess cord compression, the
decelerations nurse must assess the fetal heart rate
and the contractions will determine for any adverse changes.
the type of deceleration pattern.
31
31. A nurse has just performed a vaginal
TEST-TAKING TIP: Decelerations are defined examination on a client in labor. The nurse
by their relationship to the contraction palpates the baby’s buttocks as facing the
pattern. It is essential that the mother’s right side. Where should the
nurse determine which of the three types nurse place the external fetal monitor
of decelerations is present. Early electrode?
decelerations 1. Left upper quadrant (LUQ).
mirror contractions, late decelerations 2. Left lower quadrant (LLQ).
develop at the peak of contractions 3. Right upper quadrant (RUQ).
4. Right lower quadrant (RLQ).
3. Since the baby’s back is facing the 1. She is contracting q 5 min 60 sec.
mother’s right side and the sacrum is 2. Her cervix has dilated from 2 to 4 cm.
presenting, the fetal monitor should 3. Her membranes have ruptured.
be placed in her RUQ. 4. The fetal head is engaged.
2. Once the cervix begins to dilate, a
client is in true labor
TEST-TAKING TIP: Although the question
does not tell the test taker whether the
sacrum is facing anteriorly or posteriorly,
it does provide the information that the TEST-TAKING TIP: Although laboring
sacrum is felt toward the mother’s right. women experience contractions, contractions
Since this baby is in the sacral presentation alone are not an indicator of true
and the back is toward the right, the labor. Only when the cervix begins to
best location for the fetal monitor is in dilate is the client in true labor. False labor
the RUQ, at the level of the fetal back. contractions are usually irregular and
mild, but, in some situations, they can
32 appear to be regular and can be quite
32. Upon examination, a nurse notes that a uncomfortable.
woman is 10 cm dilated, 100% effaced, and
3 station. Which of the following actions 35
should the nurse perform during the 35. The childbirth education nurse is
next contraction? evaluating the learning of four women, 38 to
1. Encourage the woman to push. 40 weeks’ gestation, regarding when they
2. Provide firm fundal pressure. should go to the hospital. The nurse
3. Move the client into a squat. determines that the client who makes which
4. Assess for signs of rectal pressure. of the following statements needs
additional teaching?
4. Assessing for rectal pressure is 1. The client who says, “If I feel a pain in my
appropriate at this time. back and lower abdomen every
TEST-TAKING TIP: Although the test taker 5 minutes.”
may see in practice that women are 2. The client who says, “When I feel a gush
encouraged to begin to push as soon as of clear fluid from my vagina.”
they become fully dilated, it is best practice 3. The client who says, “When I go to the
to wait until the woman exhibits bathroom and see the mucus plug on
signs of rectal pressure. Pushing a baby the toilet tissue.”
that is not yet engaged may result in an 4. The client who says, “If I ever notice a
overly fatigued woman or, more significantly, greenish discharge from my vagina.”
a prolapsed cord. 134 MATERNAL AND NEWBORN SUCCESS
[Link]
33
33. A woman has decided to hire a doula to 3. Expelling the mucus plug is not sufficient
work with her during labor and delivery. reason to go to the hospital to
Which of the following actions would be be assessed
appropriate for the doula to perform?
1. Give the mother a back rub.
2. Assess the fetal heart rate. TEST-TAKING TIP: The mucus plug protects
3. Check the blood pressure. the uterine cavity from bacterial invasion.
4. Regulate the intravenous. It is expelled shortly before or
1. An appropriate action by the doula is during the early phase of labor. But, since
giving the woman a back massage. the client is exhibiting no other signs of
labor, there is no need for the client to go
to the hospital for assessment.
TEST-TAKING TIP: Even if the test taker 36
were unfamiliar with the role of the 36. A woman, 40 weeks’ gestation, calls the
doula, he or she could deduce the answer to labor unit to see whether or not she should
this question. Three of the responses go to hospital to be evaluated. Which of the
involve physiological assessments or following statements by the woman indicates
interventions. that she is probably in labor and should
Only one of the responses proceed to the hospital?
deals with providing supportive care, the 1. “The contractions are 5 to 20 minutes
role of the doula. apart.”
2. “I saw a pink discharge on the toilet tissue
34 when I went to the bathroom.”
34. The nurse is assessing a client who 3. “I have had cramping for the past 3 or 4
states, “I think I’m in labor.” Which of the hours.”
following 4. “The contractions are about a minute long
findings would positively confirm the client’s
belief?
and I am unable to talk through this afternoon, and I still feel it after
them.” waking up from my 2-hour nap.”
4. This client is exhibiting clear signs of Study These Flashcards
true labor. Not only are the contractions 3. This response indicates that the
lasting a full minute but she is stating that labor contractions are increasing in
they are so uncomfortable intensity. TEST-TAKING TIP: The test taker
that she is unable to speak through should
them. She should be seen. review the labor contraction definitions
TEST-TAKING TIP: The test taker must of frequency, duration, and intensity.
remember that nurses interpret the As labor progresses, the frequency of
comments made by gravid women who contractions decreases but the duration
are close to term. Clients, especially and the intensity, or strength, of the
primiparas, are often anxious about the contractions increase. The nurse notes
labor process and have difficulty interpreting the change when he or she palpates the
what they are feeling. Only fundus of the uterus, and the client
when the woman is experiencing subjectively
contractions complains of increasing pain.
that are increasing in intensity
and duration and decreasing in frequency 39
or has ruptured membranes 39. A nurse describes a client’s contraction
should she be encouraged to go to the pattern as: frequency every 3 min and
hospital for an evaluation. duration
60 sec. Which of the following responses
37 corresponds to this description?
37. A low-risk 38-week-gestation woman 1. Contractions lasting 60 seconds followed
calls the labor unit and says, “I have to come by a 1-minute rest period.
to the hospital right now. I just saw pink 2. Contractions lasting 120 seconds followed
streaks on the toilet tissue when I went to by a 2-minute rest period.
the bathroom. I’m bleeding.” Which of the 3. Contractions lasting 2 minutes followed by
following responses should the nurse a 60-second rest period.
make first? 4. Contractions lasting 1 minute followed by
1. “Does it burn when you void?” a 120-second rest period.
2. “You sound frightened.”
3. “That is just the mucus plug.” Study These Flashcards
4. “How much blood is there?” 4. The frequency and duration of this
contraction pattern is every 3 minutes
2. The nurse is using reflection to lasting 60 seconds.
acknowledge TEST-TAKING TIP: The test taker must
the client’s concerns. TEST-TAKING TIP: recall that frequency is defined as the
Pregnant women are time from the beginning of one contraction
very protective of themselves and of the to the beginning of the next, while
babies they are carrying. Anytime a duration is defined as the beginning
change that might portend a problem of the increment of a contraction to the
occurs, a pregnant woman is likely to end of the decrement. The only choices
become concerned and frightened. that include a frequency of 3 minutes
Certainly, seeing any kind of blood loss are choices “3” and “4,” while the only
from the vagina can be scary. The nurse choice with a duration of 60 seconds
must acknowledge that fear before is choice “4.
asking other questions or making other
comments. 40
40. A nurse determines that a client is
38 carrying a fetus in the vertical lie. The
38. A gravid client at term called the labor nurse’s
suite at 7:00 p.m. questioning whether she judgment should be questioned if the fetal
was in labor. The nurse determined that the presenting part is which of the following?
client was likely in labor after the 1. Sacrum.
client stated: 2. Occiput.
1. “At 5:00 p.m., the contractions were about 3. Mentum.
5 minutes apart. Now they’re about 4. Scapula.
7 minutes apart.”
2. “I took a walk at 5:00 p.m., and now I talk Study These Flashcards
through my contractions easier than I 4. A fetus in a scapular presentation is in
could then.” a horizontal lie.
3. “I took a shower about a half hour ago. TEST-TAKING TIP: Lie is concerned with
The contractions seem to hurt more the relationship between the fetal spine
since I finished.” and the maternal spine. When the spines
4. “I had some tightening in my belly late are parallel, the lie is vertical (or
longitudinal).
When the spines are perpendicular, for the mother?
the lie is horizontal (or transverse). 1. The anterior to posterior diameter of the
It is physiologically impossible pelvis will accommodate a fetus with
for a baby in the horizontal lie to be an average-sized head.
delivered 2. The fetal head is flexed so that it is of
vaginally. average diameter.
3. The mother’s cervix is of average dilation
41. Which of the following choices includes for the start of labor.
the correct order of the cardinal moves of 4. The distance between the mother’s
labor? physiological retraction ring and the fetal
1. Internal rotation, extension, external head is of average dimensions.
rotation.
2. External rotation, descent, extension. Study These Flashcards
3. Extension, flexion, internal rotation. 1. The obstetric conjugate is the shortest
4. External rotation, internal rotation, anterior to posterior diameter of
expulsion. the pelvis. When it is of average size,
it will accommodate an average-sized
Study These Flashcards fetal head.
41. 1. Internal rotation, extension, external
rotation is the correct sequence of the
cardinal moves of labor. TEST-TAKING TIP:
The test taker must review TEST-TAKING TIP: The obstetric conjugate
the cardinal moves of labor. There is measured by the health care practitioner
are a couple of tricks to help the test in order to estimate the potential for the fetal
taker to remember the sequence of the head to fit through the
moves of labor. First, descent and flexion anterior-posterior diameter of the
must occur first. If the baby does not maternal pelvis. It is the internal distance
descend between the sacral promontory and the
into the birth canal and the baby symphysis pubis.
does not flex the head so that his or her 44
chin is on the chest, the baby simply will The frequency of the contractions seen on
not be able to traverse through the bony the monitor tracing below is
pelvis. Second, internal rotation (rotation q __________
of the fetal body when the fetal head is
still inside the mother’s pelvis) must
occur before external rotation (rotation
of the fetal body after the fetal head is
outside the mother). In between the Study These Flashcards
rotational q 3 minutes
moves is extension, the delivery of TEST-TAKING TIP: The test taker must
the head. And, finally, expulsion must be remember three things when assessing
last since the delivery of the baby’s body frequency: (1) frequency is defined as the
is simply the last movement. time from the beginning of one contraction
to the beginning of the next contraction,
42 not the time from the end of
42. The nurse sees the fetal head through one contraction to the beginning of the
the vaginal introitus when a woman pushes. next contraction; (2) time is characterized
The nurse, interpreting this finding, tells the by a space on the graph, not by a
client, “You are pushing very well.” point; and (3) frequency is always
In addition, the nurse could also state which expressed in minutes, not seconds.
of the following?
1. “The baby’s head is engaged.” 45
2. “The baby is floating.” 45. The duration of the contractions seen on
3. “The baby is at the ischial spines.” the monitor tracing below is:
4. “The baby is almost crowning.” q ______________
Study These Flashcards
4. The baby’s head is almost crowning.
TEST-TAKING TIP: The test taker should
remember that a baby is crowning when Study These Flashcards
the mother’s perineal tissues are 90 seconds
stretched around the fetal head at the TEST-TAKING TIP: The test taker must
same location where a crown would sit. remember 3 things when assessing duration:
The station at this time is past + (1) duration of a contraction is
measured from the beginning of the
43
increment—where the contraction begins
43. A midwife advises a mother that her
to curve upward from baseline—to the
obstetric conjugate is of average size. How
end of the decrement —when the contraction
should the nurse interpret that information
returns to baseline; (2) time is
characterized by a space on the graph, it is best for the head to be in the flexed
not by a point; and (3) duration is always attitude.
written in seconds, not minutes.
48
46 48. An ultrasound report states, “The fetal
46. Which of the following frequency and head has entered the pelvic inlet.” What
duration assessments are consistent with the does the nurse interpret this statement to
pattern shown below? mean?
1. q 2 min 60 sec. 1. The fetus has become engaged.
2. q 2 min 90 sec. 2. The fetal head has entered the true pelvis.
3. q 3 min 60 sec. 3. The fetal lie is horizontal.
4. q 3 min 90 sec. 4. The fetus is in an extended attitude.
Study These Flashcards
2. The inlet’s boundaries are: the sacral
promontory and the upper margins
Study These Flashcards of the ilia, ischia, and the symphysis
4. The contraction pattern is q 3 min pubis. This is the entry into the true
90 sec pelvis.
TEST-TAKING TIP: First, the test taker
should place his or her pencil at the
beginning TEST-TAKING TIP: It is very important that
of the increment of the first contraction the test taker be familiar with the many
and the beginning of the increment definitions that are used in obstetrics. If
of the next contraction and then any of the definitions is unfamiliar, the
count the number of 10-second spaces. test taker may be confused by some of
This is the frequency once the time has the question stems or by the many answer
been converted into minutes. Next, the options.
test taker should place his or her pencil
at the beginning of the increment of the 49
first contraction and at the end of the Which of the following pictures depicts a
decrement of the same contraction and fetus in the ROP position?
count the number of 10-second spaces.
This is the duration and it should be left
in seconds.
47 Study These Flashcards
47. A woman, who is in active labor, is told 1. This is a picture of a fetus in the ROP
by her obstetrician, “Your baby is in the (right occiput posterior) position.
flexed attitude.” When she asks the nurse
what that means, what should the
nurse say? TEST-TAKING TIP: It is very important,
1. The baby is in the breech position. when determining the position of a fetus,
2. The baby is in the horizontal lie. to remember that the test taker must
3. The baby’s presenting part is engaged. consider the posture of the fetal body in
4. The baby’s chin is resting on its chest. relation to the left and/or right side of
the maternal body and not in relation to
Study These Flashcards the left and/or right side of the test
4. When the baby’s chin is on his or taker’s body
her chest, the baby is in the flexed
attitude. 50
TEST-TAKING TIP: The diameter of the 50. Which of the following pictures depicts a
fetal head is dependent upon whether or fetus in the LSA position?
not the head is flexed with the chin on
the chest or extended with the chin elevated.
When the baby is in the flexed
attitude, with the chin on the chest, the
diameter of the fetal head entering the Study These Flashcards
pelvis averages 9.5 cm (the 4. This is a picture of a fetus in the LSA
suboccipitobregmatic (left sacral anterior) position.
diameter), whereas if the baby TEST-TAKING TIP: It is very important
is in the extended attitude, with the chin when determining the position of a fetus
elevated, the diameter of the fetal head to remember that the maternal aspects of
entering the pelvis can be as large as the position—that is, left/right/etc. and
13.5 cm (the occipitomental diameter). anterior/posterior/etc.—must be determined
In order for the fetal head to pass by locating the fetal presenting
through the mother’s pelvis, therefore, part. In other words, the test taker must
determine toward which part of the
mother the presenting part of the fetus is
pointing. In this question, for example,
the sacrum of the fetus is pointing toward
the left anterior of the mother. TEST-TAKING TIP: There are many important
principles related to electronic fetal
51 heart monitoring. Variability is the most
51. Which of the following pictures depicts a important of the baseline data. Variability
fetus in the frank breech position? is a measure of the competition between
the sympathetic nervous system, which
speeds up the heart rate, and the
parasympathetic nervous system, which
slows down the heart rate. When the fetal
Study These Flashcards heart variability is adequate, the nurse
3. This is a picture of a fetus in the can conclude, therefore, that the baby’s
frank breech position. autonomic nervous system is healthy.
54
TEST-TAKING TIP: There are three main 54. The nurse is interpreting the fetal
breech positions: frank, where the buttocks monitor tracing below. Which of the following
present and both feet are located actions should the nurse take at this time?
adjacent to the fetal head; singling 1. Provide caring labor support.
footling, when one leg is extended 2. Administer oxygen via tight fitting
through the cervix and vagina while the facemask.
remaining leg is bent; and double 3. Turn the woman on her side.
footling, when both legs are extended 4. Apply the oxygen saturation electrode to
through the cervix and vagina. It is likely the mother.
that a woman carrying a breech in any
position will have a cesarean section.
52
52. During delivery, the nurse notes that the Study These Flashcards
baby’s head has just been delivered. The 1. Because the variability is moderate
nurse concludes that the baby has just gone (6 to 25 bpm wide), the nurse can
through which of the following cardinal conclude that the baby is well and
moves of labor? that caring labor support is indicated.
1. Flexion.
2. Internal rotation.
3. Extension. TEST-TAKING TIP: A tracing showing
4. External rotation. moderate
variability—that is 6 to 25 bpm
Study These Flashcards wide—indicates adequate variability and
3. During extension, the baby’s head is this, in turn, indicates normal pH and
birthed. oxygenation of the fetus. A flat tracing
indicates absent variability, while a tracing
showing minimal variability exhibits a
TEST-TAKING TIP: The baby must move pattern that is 0 to 5 bpm wide. When
through the cardinal moves because the there is no other explanation for either a
fetal head is widest anterior-posterior but the flat or minimal tracing, the drop in variability
fetal shoulders are widest laterally. is a sign of fetal hypoxia and acidosis
On the other hand, the maternal and is an obstetric emergency.
pelvis is widest laterally in the inlet but
anterior-posterior at the outlet. 55
55. After analyzing an internal fetal monitor
53 tracing, the nurse concludes that there is
53. The nurse wishes to assess the variability moderate short-term variability. Which of the
of the fetal heart rate. Which of the following interpretations should the
following actions must precede this nurse make in relation to this finding?
assessment? 1. The fetus is becoming hypoxic.
1. Place the client in the lateral recumbent 2. The fetus is becoming alkalotic.
position. 3. The fetus is in the middle of a sleep cycle.
2. Insert an internal fetal monitor electrode. 4. The fetus has a healthy nervous system.
3. Administer oxygen to the mother via face
mask. Study These Flashcards
4. Ask the mother to indicate when she feels 4. Moderate variability is indicative of
fetal movement. fetal health.
TEST-TAKING TIP: It is important for the
Study These Flashcards test taker to be familiar with situations
2. Before the variability can be accurately that can change the fetal heart variability.
assessed, an internal fetal heart Normal situations that can decrease the
electrode must be applied. variability include fetal sleep, administration
of central nervous system (CNS) Study These Flashcards
depressant medications, and prematurity. 3. Analgesics are CNS depressants. The
A normal situation that can increase the variability of the fetal heart rate,
variability is fetal activity. therefore, will be decreased.
56
56. When would the nurse expect to see the
monitor tracing shown below? TEST-TAKING TIP: It is important for the
1. During latent phase of labor. test taker to remember the side effects of
2. During an epidural insertion. commonly used medications. The analgesics
3. During second stage of labor. used in labor are opiates. The
4. During delivery of the placenta. CNS-depressant effect of the opiates is
therapeutic for the mother who is in
pain, but the baby is also affected by the
medication, often exhibiting decreased
variability.
Study These Flashcards 59
3. Early decelerations are frequently 59. The nurse is assessing an internal fetal
seen during the second stage of labor. heart monitor tracing of an unmedicated,
full-term gravida who is in transition. Which
of the following heart rate patterns
TEST-TAKING TIP: Early deceleration, one would the nurse interpret as normal?
of the three types of decelerations, is a 1. Variable baseline of 140 with V-shaped
drop in fetal heart rate that mirrors the decelerations to 120 unrelated to
contraction. It is caused by fetal head contractions.
compression. Early decelerations are 2. Variable baseline of 140 with
noted during the second stage of labor decelerations to 100 that mirror each of the
because the fetal head is compressed contractions.
against the maternal soft tissues during 3. Flat baseline of 140 with decelerations to
pushing. 120 that return to baseline after the
57 end of the contractions.
4. Flat baseline of 140 with no obvious
decelerations or accelerations.
57. When would the nurse expect to see the
fetal heart changes noted on the monitor Study These Flashcards
tracing shown below? 2. Decelerations that mirror contractions
1. During fetal movement. are early decelerations. These
2. After the administration of analgesics. are related to head compression and
3. When the fetus is acidotic. are expected during transition and
4. With poor placental perfusion. second stage labor.

Study These Flashcards

1. The fetal heart rate normally accelerates TEST-TAKING TIP: The test taker must be
during fetal movement. prepared to differentiate between normal
situations and obstetric emergencies.
Even though there are decelerations in
TEST-TAKING TIP: Fetal heart accelerations choice 2, the decelerations are expected
are usually a sign of fetal wellbeing. because the woman is currently in the
When the baby is healthy, they are transition phase of the first stage of labor
almost always noted during periods of
fetal movement. Similar to what occurs 60
in a runner, with increased movement, 60. A woman is in the second stage of labor
the fetal heart rate speeds up to with a strong urge to push. Which of the
accommodate following actions by the nurse is appropriate
increasing energy needs. at this time?
1. Assess the fetal heart rate between
58 contractions every 60 minutes.
58. A woman is in active labor and is being 2. Encourage the woman to grunt during
monitored electronically. She has just contractions.
received 3. Assess the pulse and respirations of the
Stadol 2 mg IM for pain. Which of the mother every 5 minutes.
following fetal heart responses would 4. Position the woman on her back with her
the nurse expect to see on the internal knees on her chest.
monitor tracing?
1. Variable decelerations. Study These Flashcards
2. Late decelerations. 2. The woman should be encouraged to
3. Decreased variability. grunt during contractions
4. Transient accelerations.
TEST-TAKING TIP: During second stage need to push for many more minutes so
labor, the woman should push on an it is not necessary to notify the health
open glottis to prevent the vasovagal care provider (HCP) until additional
response. Research has shown that when signs are noted.
women push without being coached,
they do not hold their breaths to bear 63
down, but instead grunt during the 63. A multipara, LOA, station 3, who has had
second stage no pain medication during her labor, is
now in stage 2. She states that her pain is 6
61 on a 10-point scale and that she wants
61. A nurse is coaching a woman who is in an epidural. Which of the following responses
the second stage of labor. Which of the by the nurse is appropriate?
following should the nurse encourage the 1. “Epidurals do not work well when the pain
woman to do? level is above level 5.”
1. Hold her breath for twenty seconds during 2. “I will contact the doctor to get an order
every contraction. for an epidural right away.”
2. Blow out forcefully during every 3. “The baby is going to be born very soon. It
contraction. is really too late for an epidural.”
3. Push between contractions until the fetal 4. “I will check the fetal heart rate. You can
head is visible. have an epidural if it is over 120.”
4. Take a slow cleansing breath before
bearing down. Study These Flashcards
3. Since this woman is a multipara, the
Study These Flashcards position is LOA and the station is 3,
4. By taking a slow, cleansing breath this is an accurate statement.
before pushing, the woman is waiting
until the contraction builds to its
peak. Her pushes will be more effective TEST-TAKING TIP: The average length of
at this point in the contraction. the second stage of labor for multiparas is
TEST-TAKING TIP: It is essential that the about 15 minutes. Plus, the fetus in the
test taker read each question and the scenario has already descended to 3
possible answer options carefully. If the station and is in the optimal position for
test taker were to read response “3” delivery—LOA. It is very likely that this
quickly, he or she might mistakenly baby will be born in a few contractions.
choose it as the correct response. Because The nurse should encourage the client to
the woman is being encouraged to continue pushing with her contractions
push between contractions, however, the
answer is incorrect. 64
64. A pregnant woman is discussing
62 positioning and the use of leg stirrups for
62. A primigravida is pushing with delivery
contractions. The nurse notes that the with a labor nurse. In which of the following
woman’s perineum instances should the nurse provide
is beginning to bulge and that there is an further information to the client?
increase in bloody show. Which of 1. When the client states, “I am glad that
the following actions by the nurse is deliveries can take place in a variety of
appropriate at this time? places, including a Jacuzzi bathtub.”
1. Report the findings to the woman’s health 2. When the client says, “I heard that for
care practitioner. doctors to deliver babies safely, it is
2. Immediately assess the woman’s pulse essential to have the mother’s legs up in
and blood pressure. stirrups.”
3. Provide encouragement during each 3. When the client says, “During difficult
contraction. deliveries it is sometimes necessary to
4. Place the client on her side with oxygen put a woman’s legs up in stirrups.”
via face mask. 4. When the client states, “I heard that
Study These Flashcards midwives often deliver their patients either
3. Since this is a normal finding, the in the side-lying or squatting position.”
nurse should continue to provide labor Study These Flashcards
support and encouragement 2. The nurse should provide additional
information to this client. Many deliveries
are performed safely without
TEST-TAKING TIP: The bulging perineum stirrups.
is an indication that the baby is descending
in the birth canal and the bloody TEST-TAKING TIP: Deliveries can be
show results from injury to the capillaries performed
in the mother’s cervix. Because this in a variety of positions, including
woman is a primigravida, she will likely lithotomy, squatting, and side-lying;
in a variety of locations, including labor
bed, delivery bed, toilet, shower, and in a 2. These are signs of placental delivery.
dry environment or water. It is recommended
that mothers consult with their
health care practitioners early in the TEST-TAKING TIP: Although they sound
pregnancy regarding the practitioner’s abnormal, the following are the normal
delivery practices, including birth positions. signs of placental separation: the uterus
The mother’s birth preference may rises in the abdomen and becomes globular,
influence her choice of caregiver there is a gush of blood expelled
from the vagina, and the umbilical cord
lengthens. The placenta should be delivered
65 between 5 and 30 minutes after the
65. During the third stage, the following delivery of the baby.
physiological changes occur. Please place
the 67
changes in chronological order. 67. A client is in the third stage of labor.
1. Hematoma forms behind the placenta. Which of the following assessments should
2. Membranes separate from the uterine the nurse make/observe for?
wall. 1. Fetal heart assessment after each
3. The uterus contracts firmly. contraction.
4. The uterine surface area dramatically 2. Uterus rising in the abdomen and feeling
decreases. globular.
3. Rapid cervical dilation to ten centimeters.
Study These Flashcards 4. Maternal complaints of intense rectal
The order of change during the third pressure.
stage of labor is: 3, 4, 1, 2
3. The contraction of the uterus after Study These Flashcards
delivery 2. This is a sign of placental separation
of the baby is the first step in the
third stage of labor.
4. As the uterus contracts, its surface area TEST-TAKING TIP: It is essential that the
decreases more and more. test taker clearly differentiate between
1. A hematoma forms behind the placenta stage 1, stage 2, and stage 3 of labor.
as the placenta separates from the uterine Stage 1, what is usually referred to as
wall after the uterus has contracted and “labor,” ends with full cervical dilation.
its surface area has decreased. At the end of stage 2, the baby is born.
2. The membranes separate from the uterine And at the conclusion of stage 3, the
wall after the placenta separates and placenta is born..
begins to be born. 68
TEST-TAKING TIP: The test taker should 68. A woman is in the transition phase of
become familiar with the process of labor. Which of the following comments
placental should the nurse expect to hear?
separation. Once the baby is born, 1. “I am so excited to be in labor.”
the uterus contracts. When it does so, the 2. “I can’t stand this pain any longer!”
surface area of the internal uterine 3. “I need ice chips because I’m so hot.”
wall decreases, forcing the placenta to 4. “I have to push the baby out right now!”
begin to separate. As the placenta separates,
a hematoma forms behind it, Study These Flashcards
further promoting placental separation. 2. This comment is consistent with a
Once the placenta separates and begins woman in the transition phase of
to be born, the membranes peel off the stage 1.
uterine wall and are delivered last.
TEST-TAKING TIP: The test taker must be
66 familiar not only with the physiological
66. A woman had a baby by normal changes that occur during each phase of
spontaneous delivery 10 minutes ago. The labor but also with the maternal behaviors
nurse that are expected at each phase.
notes that a gush of blood was just expelled
69
from the vagina and the umbilical cord
69. A client in labor is talkative and happy.
lengthened. What should the nurse
How many centimeters dilated would a
conclude?
maternity nurse suspect that the client is at
1. The woman has an internal laceration.
this time?
2. The woman is about to deliver the
1. 2 cm.
placenta.
2. 4 cm.
3. The woman has an atonic uterus.
3. 8 cm.
4. The woman is ready to expel the cord
4. 10 cm.
bloods.
Study These Flashcards
Study These Flashcards
1. The nurse would expect the woman dilation, the contraction pattern, and the
to be 2 cm dilated. fetal heart pattern. The woman is clearly
in the latent phase because she is only 2 cm
dilated, 30% effaced, and is contracting
TEST-TAKING TIP: In the latent phase of infrequently at q 12 minutes
labor, clients are often very excited because with short duration. Plus, the fetal heart
the labor has finally begun. They rate is excellent. She could be sent home
frequently are very talkative and easily to labor in comfort.
distracted from the discomfort of the 72
contractions. The test taker should be 72. A nurse concludes that a woman is in the
familiar with the cervical changes that latent phase of labor. Which of the following
correlate with the various phases and signs/symptoms would lead a nurse to that
stages of labor. conclusion?
70 1. The woman talks and laughs during
70. A nurse is assessing the vital signs of a contractions.
client in labor at the peak of a contraction. 2. The woman complains about severe back
Which of the following findings would the labor.
nurse expect to see? 3. The woman performs effleurage during a
1. Decreased pulse rate. contraction.
2. Hypertension. 4. The woman asks to go to the bathroom to
3. Hyperthermia defecate.
4. Decreased respiratory rate. Study These Flashcards
Study These Flashcards 1. Talking and laughing are characteristic
2. The blood pressure rises dramatically behaviors of the latent phase.

TEST-TAKING TIP: During contractions,

the blood from the placenta is forced TEST-TAKING TIP: Although effleurage is a
into the peripheral vascular system and massage that women are taught to use
there is an increase in cardiac output. during the latent phase of labor, it is
As a result, the woman’s blood pressure important for the test taker to remember
rises: an average of 35 mm Hg systolic that women are individuals and are
and 25 mm Hg diastolic. The blood pressure encouraged to use breathing techniques
should never be assessed during a and other therapies that help them with
contraction because the reading will be a their labors. Some women enjoy performing
marked distortion of the woman’s true massage well into the active and
blood pressure. transition phases and others never find it
71 comforting.
71. A woman, G1 P0000, 40 weeks’ 73
gestation, entered the labor suite stating 73. A G1P0, 8 cm dilated, is to receive pain
that she is medication. The health care practitioner
in labor. Upon examination it is noted that has decided to order an opiate analgesic with
the woman is 2 cm dilated, 30% effaced, an analgesic-potentiating medication.
contracting every 12 min 30 sec. Fetal heart Which of the following medications would the
rate is in the 140s with good variability nurse expect to be ordered as the
and spontaneous accelerations. What should analgesic-potentiating medication?
the nurse conclude when reporting 1. Seconal (secobarbital).
the findings to the primary health care 2. Phenergan (promethazine).
practitioner? 3. Benadryl (diphenhydramine).
1. The woman is high risk and should be 4. Tylenol (acetaminophen).
placed on tocolytics.
2. The woman is in early labor and could be Study These Flashcards
sent home. 2. Phenergan is often used as an analgesic
3. The woman is high risk and could be potentiator.
induced.
4. The woman is in active labor and should
be admitted to the unit. TEST-TAKING TIP: Phenergan is a valuable
analgesic potentiator, not only because it
Study These Flashcards helps to increase the effectiveness of the
2. The woman is in early labor. There is analgesic but also because it acts as an
no need for her to be hospitalized at antiemetic. Women often vomit during
this time. transition. Phenergan as well as other
medications like Reglan (metoclopramide)
and Vistaril (hydroxyzine) help
TEST-TAKING TIP: The key facts that the to diminish the nausea associated with
test taker should attend to in this question the analgesic as well as the vomiting
about a primigravida are the cervical
associated 76. Which of the following actions would the
with transition. nurse expect to perform immediately before
a woman is to have regional anesthesia?
74 Select all that apply.
74. On vaginal examination, it is noted that a 1. Assess fetal heart rate.
woman with a well-functioning epidural 2. Infuse 1000 cc of Ringer’s lactate.
is in the second stage of labor. The station is 3. Place woman in Trendelenburg position.
2 and the baseline fetal heart rate is 4. Monitor blood pressure every 5 minutes
130 with no decelerations. Which of the for 15 minutes.
following nursing actions is appropriate at 5. Have woman empty her bladder.
this time?
1. Coach the woman to hold her breath while Study These Flashcards
pushing 3 to 4 times with each 76. 1, 2, and 5 are correct.
contraction. 1. Before a woman is given regional
2. Administer oxygen via face mask at 8 to anesthesia, the nurse should assess
10 liters per minute. the fetal heart rate.
3. Delay pushing until the baby descends 2. The nurse should infuse Ringer’s lactate
further and the mother has a strong urge before the woman is given regional
to push. anesthesia.
4. Place the woman on her side and assess
her oxygen saturation.
Study These Flashcards 5. The nurse should ask the woman to
3. Once the woman has a strong urge to empty her bladder.
push, then she should be encouraged TEST-TAKING TIP: Before any medication,
to push against an open glottis in order whether analgesia or anesthesia, is
to birth the baby. administered
during labor, the fetal heart
TEST-TAKING TIP: Although the use of an should be assessed to make sure that the
epidural is not high risk, there can be injuries baby is not already compromised. Before
to the maternal birth canal and/or regional anesthesia administration, a liter
the fetus when pushing is performed by a of fluid should be infused to increase the
mother with no feeling. It is recommended woman’s vascular fluid volume. This will
that women who have lost all help to maintain her blood pressure after
feeling because of an epidural “labor the epidural insertion. And the woman’s
down,” or rest and wait, until the urge to bladder should be emptied because she will
push returns. Once that happens, the not have the sensation of a full bladder
woman should perform open glottal once the epidural is in place.
pushing.
77
77. Immediately following administration of
an epidural anesthesia, the nurse must
75 monitor the mother for which of the
75. A nurse is assisting an anesthesiologist following?
who is inserting an epidural catheter. Which 1. Paresthesias in her feet and legs.
of the following positions should the nurse 2. Drop in blood pressure.
assist the woman into? 3. Increase in central venous pressure.
1. Fetal position. 4. Fetal heart accelerations.
2. Lithotomy position.
3. Trendelenburg position. Study These Flashcards
4. Lateral recumbent position. 2. Hypotension is a very common side
effect of regional anesthesia.
Study These Flashcards
1. The woman should be helped into the TEST-TAKING TIP: The test taker must be
fetal position. familiar with the side effects of all
medications.
If no other therapeutic interventions
TEST-TAKING TIP: In order for the are performed, virtually all
anesthesiologist women will show signs of hypotension
to be able to insert the after epidural administration. The
epidural catheter into the epidural space, change is related to two phenomena:
the woman must be placed in either the dilation of the vessels in the pelvis and
fetal position or sitting with her chin on increased compression of the vena cava.
her chest and her back convex. In both of 78
those positions, the woman’s vertebrae 78. A client, G2P1001, 5 cm dilated and 40%
separate, providing the anesthesiologist effaced, has just received an epidural.
access to the required space. Which of the following actions is important
76 for the nurse to make at this time?
1. Assess the woman’s temperature.
2. Place a wedge under the woman’s side. 140 mg/dL only if the mother had diabetes.
3. Place a blanket roll under the woman’s The only expected value listed is
feet. a pH of 7.30 since this is consistent with
4. Assess the woman’s pedal pulses. a normal, slightly acidic fetal pH. The
differences in fetal and extrauterine
Study These Flashcards values reflect the fact that the fetus is
2. A wedge should be placed under one not oxygenating efficiently through the
side of the woman lungs, as happens in the extrauterine
environment, but rather is “breathing”
indirectly via the placenta.
TEST-TAKING TIP: The test taker must
remember 81
that hypotension is the most 81. Which of the following actions is
common complication of epidural anesthesia appropriate for the nurse to perform when
in labor. One of the most important caring
reasons for this is the compression for a Chinese-speaking woman in active
of the vena cava by the pregnant uterus. labor?
When a wedge is placed under the 1. Apply heat to the woman’s back.
woman’s side—usually the right side— 2. Inquire regarding the woman’s pain level.
the uterus is tilted, relieving the pressure 3. Make sure that the woman’s head is
on the great vessels. covered.
4. Accept the woman’s loud verbalizations.
79
79. The practitioner is performing a fetal Study These Flashcards
scalp stimulation test. Which of the following 2. It is important to inquire about the
fetal responses would the nurse expect to pain level of all women in labor,
see? but especially those from the Asian
1. Spontaneous fetal movement. culture
2. Fetal heart acceleration.
3. Increase in fetal heart variability.
4. Resolution of late decelerations. TEST-TAKING TIP: Childbearing and
childrearing are fraught with cultural
Study These Flashcards implications. It is essential that the nurse
2. The fetal heart should accelerate in understand the many cultural beliefs of
response to scalp stimulation clients for whom they will care. Chinese
women are often expected to be quiet
during labor. Even when in severe pain,
TEST-TAKING TIP: The fetal scalp stimulation they often remain stoic and uncomplaining.
test is performed by the health care It is essential, therefore, that the
practitioner when the fetal heart pattern nurse repeatedly question them regarding
is equivocal. For example, if the variability their level of pain using an objective
is questionable, the practitioner may pain scale.
perform the stimulation test. If the fetal
heart rate accelerates in response to the 82
test, the nurse interprets the response as 82. A nurse is caring for women from four
a positive sign. different countries. Which of the women is
most likely to request that her head be kept
80 covered throughout her hospitalization?
80. The nurse is interpreting the results of a 1. Arabic woman.
fetal blood sampling test. Which of the 2. Chinese woman.
following reports would the nurse expect to 3. Russian woman.
see? 4. Greek woman.
1. Oxygen saturation of 99%.
2. Hgb of 11 gm/dL. Study These Flashcards
3. Serum glucose of 140 mg/dL. 1. Muslim women, who are often from
4. pH of 7.30. Arabic countries, are expected to keep
their heads covered at all times.
Study These Flashcards
4. This fetal pH value is within normal
limits. TEST-TAKING TIP: There are two groups
TEST-TAKING TIP: It is essential that the of women who are likely to request that
test taker be aware that many fetal lab their heads be covered at all times—
values are much different than those observant Jews and Muslims. Many
seen in extrauterine life. The nurse Arabic women are Muslim; therefore,
would expect to see fetal oxygen saturation the nurse should ask whether or not
of 50% to 75%, not 99%, and fetal they would like head coverings.
hemoglobin levels of 14 to 20 gm/dL, Observant or Orthodox Jewish women
not 11 gm/dL. The nurse would expect also will usually request that their heads
to see a fetal serum glucose level of
be covered. It is very important that some educated guesses by remembering
religious requests be met with acceptance that pharmacological medications for labor
by the health care staff. induction are prostaglandins and
oxytocin. When a woman has an orgasm
during intercourse, she releases oxytocin.
83 Nipple and breast massage also stimulate
83. The nurse is caring for an Orthodox oxytocin production. And evening primrose
Jewish woman in labor. It would be oil contains a fatty acid that converts
appropriate into a prostaglandin compound.
for the nurse to include which of the
following in the plan of care?
1. Encourage the father to hold his partner’s
hand during labor.
2. Ask the woman if she would like to speak 85
with her priest. 85. The nurse is providing acupressure to
3. Provide the woman with a long-sleeved provide pain relief to a woman in labor.
hospital gown. Where is the best location for the
4. Place an order for the woman’s acupressure to be applied?
postpartum vegetarian diet. 1. On the malleolus of the wrist.
2. Above the patella of the knee.
Study These Flashcards 3. On the medial aspect of the lower leg.
3. Observant Jewish women are expected 4. Below the medial epicondyle of the elbow.
to have their elbows covered at
all times. A long-sleeved gown, therefore, Study These Flashcards
should be provided for them. 3. The medial surface of the lower leg
has been shown to lessen the pain
of labor
TEST-TAKING TIP: There are a number of
religious mandates that guide the lives of
Jewish couples. The mandates surround TEST-TAKING TIP: Complementary therapies
everyday life—what to eat, what to wear, have been shown to be of value in a
when work is allowed, and when it is number of clinical situations, including
prohibited—as well as life events— labor. The specific acupressure point for
sexuality and birthing. The nurse should labor pain is located about 3 cm above
have some familiarity with the many the inner malleolus in the calf region. An
precepts of the Jewish religion in order additional acupressure point is found at
to care for that population with cultural the depression at the top one third of the
competence. sole of the foot. Strong pressure placed
at these points has been shown to reduce
84 the pain of labor contractions.
84. Which of the following
nonpharmacological interventions 86
recommended by nurse 86. To decrease the possibility of a perineal
midwives may help a client at full term to go laceration during delivery, the nurse
into labor? Select all that apply. performs which of the following interventions
1. Engage in sexual intercourse. prior to the delivery?
2. Ingest evening primrose oil. 1. Assists the woman into a squatting
3. Perform yoga exercises. position.
4. Eat raw spinach. 2. Advises the woman to push only when she
5. Massage the breast and nipples. feels the urge.
3. Encourages the woman to push slowly and
Study These Flashcards steadily.
1, 2, and 5 are correct. 4. Massages the perineum with mineral oil.
1. Nurse midwives sometimes recommend
that women at full term engage Study These Flashcards
in sexual intercourse to stimulate labor. 4. Massaging of the perineum with mineral
2. Ingesting primrose oil is also sometimes oil does help to reduce perineal
recommended. Primrose oil is tearing.
believed to help ripen the cervix.

and nurse midwives often massage a

5. Nipple and breast massage is sometimes woman’s perineum to increase the elasticity
recommended to help induce of the tissue. Because the tissue is
labor. more elastic, it is less inclined to tear
TEST-TAKING TIP: If the test taker was during the delivery. In addition, mothers
unfamiliar with nonpharmacological are often encouraged to begin massaging
induction the tissue during their last trimester.
methods, he or she could make 87
87. The physician writes the following order TEST-TAKING TIP: During pregnancy and
for a newly admitted client in labor: early labor, the cervix is closed, long, and
Begin a 1000 cc IV of D5 1/2 NS at 150 cc/hr. thick. During the labor process, however,
The IV tubing states that the drop the cervix changes shape, becoming paper
factor is 10 gtt/cc. Calculate the drip rate. thin and dilating to 10 cm. This is a
_______ gtt/min universal finding. No matter how tall or
short, old or young a woman is, her
Study These Flashcards cervix will dilate to 10 cm and efface
25 gtt/min 100% if she has a vaginal delivery.
Formula for drip rate calculations:
volume in cc drop factor 90
time in minutes 90. It is 4 p.m. A client, G1P0000, 3 cm
150 cc 10 gtt/cc dilated, asks the nurse when the dinner tray
will be served. The nurse replies
150 1. “Laboring clients are never allowed to
60 min 6 eat.”
150 2. “Believe me, you will not want to eat by
25 gtt/min the time it is the dinner hour. Most
6 women throw up, you know.”
TEST-TAKING TIP: Please note that when 3. “The dinner tray should arrive in an hour
the units for each of the numbers is or two.”
included, the test taker will never make 4. “A heavy meal is discouraged. I can get
a mistake with drip rate calculations clear fluids for you whenever you would
because, as can be seen above, the cc’s like them, though.”
are cancelled out and what remains is
the required units, gtt/min. Study These Flashcards
4. This is the best response.
88 TEST-TAKING TIP: Peristalsis slows
88. The health care practitioner orders the dramatically
following medication for a laboring client: during labor. Because of this,
Stadol 0.5 mg IV stat for pain. The drug is on women rarely become hungry during
hand in the following concentration: labor, but they do need fluids and some
Stadol 2 mg/mL. How many mL of medication nourishment. Clear fluids, including ice
will the nurse administer? chips, water, tea, and bouillon, are often
_____ mL allowed. Ultimately, though, it is the
health care practitioner’s decision what
Study These Flashcards and how much the client may consume.
0.25 mL
Formula for calculating the volume of
medication to be administered:
Known dosage : known value desired 1.A nurse is caring for a client in labor. The
dosage : desired volume nurse determines that the client is beginning
2 mg : 1 mL 0.5 mg : x mL in the 2nd stage of labor when which of the
2 mg x 0.5 mg following assessments is noted?
x 0.25 mL
TEST-TAKING TIP: This is a simple ratio [Link] client begins to expel clear vaginal
and proportion problem. The known is fluid
placed on one side of the equation [Link] contractions are regular
(2 mg/mL) and the desired is placed on [Link] membranes have ruptured
the other side of the equation (0.5 mg/x [Link] cervix is dilated completely
mL). To solve the problem, the nurse 1.4. The second stage of labor begins when
simply must cross multiply. the cervix is dilated completely and ends
with the birth of the neonate.
89
89. The nurse is performing a vaginal A nurse in the labor room is caring for a
examination on a client in labor. The client is client in the active phases of labor. The
found to be 5 cm dilated, 90% effaced, and nurse is assessing the fetal patterns and
station 2. Which of the following has notes a late deceleration on the monitor
the nurse palpated? strip. The most appropriate nursing action is
1. Thin cervix. to:
2. Bulging fetal membranes.
3. Head at the pelvic outlet. [Link] the mother in the supine position
4. Closed cervix. [Link] the findings and continue to
monitor the fetal patterns
Study These Flashcards [Link] oxygen via face mask
1. The cervix is thin [Link] the rate of pitocin IV infusion

3. Late decelerations are due to

uteroplacental insufficiency as the result of
decreased blood flow and oxygen to the the mother abdomen
fetus during the uterine contractions. This [Link] Leopold's maneuvers first to
causes hypoxemia; therefore oxygen is determine the location of the fetal heart
necessary. The supine position is avoided [Link] the maternal radial pulse while
because it decreases uterine blood flow to listening to the fetal heart rate
the fetus. The client should be turned to her
side to displace pressure of the gravid uterus 4. The nurse simultaneously should palpate
on the inferior vena cava. An intravenous the maternal radial or carotid pulse and
pitocin infusion is discontinued when a late auscultate the fetal heart rate to
deceleration is noted. differentiate the two. If the fetal and
maternal heart rates are similar, the nurse
A nurse is performing an assessment of a may mistake the maternal heart rate for the
client who is scheduled for a cesarean fetal heart rate. Leopold's maneuvers may
delivery. Which assessment finding would help the examiner locate the position of the
indicate a need to contact the physician? fetus but will not ensure a distinction
between the two rates.
[Link] heart rate of 180 beats per minute
[Link] blood cell count of 12,000 A nurse is caring for a client in labor who is
[Link] pulse rate of 85 beats per minute receiving Pitocin by IV infusion to stimulate
[Link] of 11.0 g/dL uterine contractions. Which assessment
finding would indicate to the nurse that the
1. A normal fetal heart rate is 120-160 beats infusion needs to be discontinued?
per minute. A count of 180 beats per minute
could indicate fetal distress and would [Link] contractions occurring within a 10-
warrant physician notification. By full term, a minute period
normal maternal hemoglobin range is 11-13 2.A fetal heart rate of 90 beats per minute
g/dL as a result of the hemodilution caused [Link] resting tone of the uterus
by an increase in plasma volume during palpated between contractions
pregnancy. [Link] urinary output

A client in labor is transported to the delivery 2. A normal fetal heart rate is 120-160 BPM.
room and is prepared for a cesarean Bradycardia or late or variable decelerations
delivery. The client is transferred to the indicate fetal distress and the need to
delivery room table, and the nurse places the discontinue to pitocin. The goal of labor
client in the: augmentation is to achieve three good-
quality contractions in a 10-minute period.
[Link]'s position with the legs in
stirrups A nurse is beginning to care for a client in
[Link]-Fowler position with a pillow under labor. The physician has prescribed an IV
the knees infusion of Pitocin. The nurse ensures that
[Link] position with the legs separated and which of the following is implemented before
elevated initiating the infusion?
[Link] position with a wedge under the
right hip [Link] the client on complete bed rest
[Link] electronic fetal monitoring
4. Vena cava and descending aorta [Link] IV infusion of antibiotics
compression by the pregnant uterus impedes [Link] a code cart at the client's bedside
blood return from the lower trunk and
extremities. This leads to decreasing cardiac 2. Continuous electronic fetal monitoring
return, cardiac output, and blood flow to the should be implemented during an IV infusion
uterus and the fetus. The best position to of Pitocin.
prevent this would be side-lying with the
uterus displaced off of abdominal vessels. A nurse is monitoring a client in active labor
Positioning for abdominal surgery and notes that the client is having
necessitates a supine position; however, a contractions every 3 minutes that last 45
wedge placed under the right hip provides seconds. The nurse notes that the fetal heart
displacement of the uterus. rate between contractions is 100 BPM. Which
of the following nursing actions is most
A nurse is caring for a client in labor and appropriate?
prepares to auscultate the fetal heart rate by
using a Doppler ultrasound device. The nurse [Link] the client's coach to continue to
most accurately determines that the fetal encourage breathing exercises
heart sounds are heard by: [Link] the client to continue pushing
with each contraction
[Link] if the heart rate is greater than 140 [Link] monitoring the fetal heart rate
BPM [Link] the physician or nurse mid-wife
[Link] the diaphragm of the Doppler on
4. A normal fetal heart rate is 120-160 beats presenting part is 1 cm above the ischial
per minute. Fetal bradycardia between spines.
contractions may indicate the need for A pregnant client is admitted to the labor
immediate medical management, and the room. An assessment is performed, and the
physician or nurse mid-wife needs to be nurse notes that the client's hemoglobin and
notified. hematocrit levels are low, indicating anemia.
The nurse determines that the client is at
A nurse is caring for a client in labor and is risk for which of the following?
monitoring the fetal heart rate patterns. The
nurse notes the presence of episodic 1.A loud mouth
accelerations on the electronic fetal monitor [Link] self-esteem
tracing. Which of the following actions is [Link]
most appropriate? [Link] infections
4. Anemic women have a greater likelihood
[Link] the findings and tell the mother of cardiac decompensation during labor,
that the monitor indicates fetal well-being postpartum infection, and poor wound
[Link] the mothers vital signs and tell the healing. Anemia does not specifically present
mother that bed rest is required to conserve a risk for hemorrhage. Having a loud mouth
oxygen. is only related to the person typing up this
[Link] the physician or nurse mid-wife of test.
the findings. A nurse assists in the vaginal delivery of a
[Link] the mother and check the newborn infant. After the delivery, the nurse
monitor for changes in the fetal tracing observes the umbilical cord lengthen and a
spurt of blood from the vagina. The nurse
1. Accelerations are transient increases in documents these observations as signs of:
the fetal heart rate that often accompany
contractions or are caused by fetal [Link]
movement. Episodic accelerations are [Link] previa
thought to be a sign of fetal-well being and [Link] atony
adequate oxygen reserve. [Link] separation
A nurse is admitting a pregnant client to the 4. As the placenta separates, it settles
labor room and attaches an external downward into the lower uterine segment.
electronic fetal monitor to the client's The umbilical cord lengthens, and a sudden
abdomen. After attachment of the monitor, trickle or spurt of blood appears.
the initial nursing assessment is which of the A client arrives at a birthing center in active
following? labor. Her membranes are still intact, and
the nurse-midwife prepares to perform an
[Link] the types of accelerations amniotomy. A nurse who is assisting the
[Link] the baseline fetal heart rate nurse-midwife explains to the client that
[Link] the frequency of the after this procedure, she will most likely
contractions have:
[Link] the intensity of the
contractions [Link] pressure on her cervix
[Link] efficiency of contractions
2. Assessing the baseline fetal heart rate is [Link] number of contractions
important so that abnormal variations of the [Link] need for increased maternal blood
baseline rate will be identified if they occur. pressure monitoring
2. Amniotomy can be used to induce labor
Options 1 and 3 are important to assess, but when the condition of the cervix is favorable
not as the first priority. (ripe) or to augment labor if the process
A nurse is reviewing the record of a client in begins to slow. Rupturing of membranes
the labor room and notes that the nurse allows the fetal head to contact the cervix
midwife has documented that the fetus is at more directly and may increase the
-1 station. The nurse determines that the efficiency of contractions.
fetal presenting part is: A nurse is monitoring a client in labor. The
nurse suspects umbilical cord compression if
1.1 cm above the ischial spine which of the following is noted on the
2.1 fingerbreadth below the symphysis pubis external monitor tracing during a
3.1 inch below the coccyx contraction?
4.1 inch below the iliac crest
1. Station is the relationship of the [Link] decelerations
presenting part to an imaginary line drawn [Link] decelerations
between the ischial spines, is measured in [Link] decelerations
centimeters, and is noted as a negative [Link]-term variability
number above the line and a positive 2. Variable decelerations occur if the
number below the line. At -1 station, the fetal umbilical cord becomes compressed, thus
reducing blood flow between the placenta
and the fetus. Early decelerations result from A nurse is assigned to care for a client with
pressure on the fetal head during a hypotonic uterine dysfunction and signs of a
contraction. Late decelerations are an slowing labor. The nurse is reviewing the
ominous pattern in labor because it suggests physician's orders and would expect to note
uteroplacental insufficiency during a which of the following prescribed treatments
contraction. Short-term variability refers to for this condition?
the beat-to-beat range in the fetal heart rate.
A nurse explains the purpose of effleurage to [Link] that will provide sedation
a client in early labor. The nurse tells the [Link] hydration
client that effleurage is: [Link] (Pitocin) infusion
[Link] of a tocolytic medication
1.A form of biofeedback to enhance bearing
down efforts during delivery 3. Therapeutic management for hypotonic
[Link] stroking of the abdomen to facilitate uterine dysfunction includes oxytocin
relaxation during labor and provide tactile augmentation and amniotomy to stimulate a
stimulation to the fetus labor that slows.
[Link] application of pressure to the sacrum
to relieve a backache A nurse in the labor room is preparing to
[Link] to stimulate uterine activity by care for a client with hypertonic uterine
contracting a specific muscle group while dysfunction. The nurse is told that the client
other parts of the body rest is experiencing uncoordinated contractions
2. Effleurage is a specific type of cutaneous that are erratic in their frequency, duration,
stimulation involving light stroking of the and intensity. The priority nursing
abdomen and is used before transition to intervention would be to:
promote relaxation and relieve mild to
moderate pain. Effleurage provides tactile [Link] the Pitocin infusion closely
stimulation to the fetus. [Link] pain relief measures
A nurse is caring for a client in the second [Link] the client for an amniotomy
stage of labor. The client is experiencing [Link] ambulation every 30 minutes
uterine contractions every 2 minutes and 2. Management of hypertonic labor depends
cries out in pain with each contraction. The on the cause. Relief of pain is the primary
nurse recognizes this behavior as: intervention to promote a normal labor
pattern.
[Link]
[Link] of losing control A nurse is developing a plan of care for a
[Link] grunting client experiencing dystocia and includes
[Link]'s maneuver several nursing interventions in the plan of
2. Pains, helplessness, panicking, and fear of care. The nurse prioritizes the plan of care
losing control are possible behaviors in the and selects which of the following nursing
2nd stage of labor. interventions as the highest priority?
A nurse is monitoring a client in labor who is
receiving Pitocin and notes that the client is [Link] the significant other informed of
experiencing hypertonic uterine contractions. the progress of the labor
List in order of priority the actions that the [Link] comfort measures
nurse takes. [Link] fetal heart rate
[Link] the client's position frequently
[Link] of Pitocin infusion
[Link] a vaginal examination 3. The priority is to monitor the fetal heart
[Link] the client rate.
[Link] the client's blood pressure and heart
rate A maternity nurse is preparing to care for a
[Link] oxygen by face mask at 8 to 10 pregnant client in labor who will be
L/min delivering twins. The nurse monitors the fetal
1, 4, 2. 5, 3. heart rates by placing the external fetal
monitor:
If uterine hypertonicity occurs, the nurse
immediately would intervene to reduce [Link] the fetus that is most anterior to the
uterine activity and increase fetal mothers abdomen
oxygenation. The nurse would stop the [Link] the fetus that is most posterior to the
Pitocin infusion and increase the rate of the mothers abdomen
nonadditive solution, check maternal BP for [Link] that each fetal heart rate is monitored
hyper or hypotension, position the woman in separately
a side-lying position, and administer oxygen [Link] that one fetus is monitored for a 15-
by snug face mask at 8-10 L/min. The nurse minute period followed by a 15 minute fetal
then would attempt to determine the cause monitoring period for the second fetus
of the uterine hypertonicity and perform a 3. In a client with a multi-fetal pregnancy,
vaginal exam to check for prolapsed cord each fetal heart rate is monitored separately.
 nurse should push the call light to summon
A nurse in the postpartum unit is caring for a help, and other staff members should call the
client who has just delivered a newborn physician and notify the delivery room. No
infant following a pregnancy with placenta attempt should be made to replace the cord.
previa. The nurse reviews the plan of care The examiner, however, may place a gloved
and prepares to monitor the client for which hand into the vagina and hold the presenting
of the following risks associated with part off of the umbilical cord. Oxygen at 8 to
placenta previa? 10 L/min by face mask is delivered to the
mother to increase fetal oxygenation.
[Link] intravascular coagulation
[Link] hypertension A maternity nurse is caring for a client with
[Link] abruptio placenta and is monitoring the
[Link] client for disseminated intravascular
coagulopathy. Which assessment finding is
4. Because the placenta is implanted in the least likely to be associated with
lower uterine segment, which does not disseminated intravascular coagulation?
contain the same intertwining musculature
as the fundus of the uterus, this site is more [Link] of the calf in one leg
prone to bleeding. [Link] clotting times
[Link] platelet count
A nurse in the delivery room is assisting with [Link], oozing from injection sites, and
the delivery of a newborn infant. After the hematuria
delivery of the newborn, the nurse assists in
delivering the placenta. Which observation 1. DIC is a state of diffuse clotting in which
would indicate that the placenta has clotting factors are consumed, leading to
separated from the uterine wall and is ready widespread bleeding. Platelets are decreased
for delivery? because they are consumed by the process;
coagulation studies show no clot formation
[Link] umbilical cord shortens in length and (and are thus normal to prolonged); and
changes in color fibrin plugs may clog the microvasculature
2.A soft and boggy uterus diffusely, rather than in an isolated area. The
[Link] complaints of severe uterine presence of petechiae, oozing from injection
cramping sites, and hematuria are signs associated
[Link] in the shape of the uterus with DIC. Swelling and pain in the calf of one
leg are more likely to be associated with
4. Signs of placental separation include thrombophebitis.
lengthening of the umbilical cord, a sudden
gush of dark blood from the introitus A nurse is assessing a pregnant client in the
(vagina), a firmly contracted uterus, and the 2nd trimester of pregnancy who was
uterus changing from a discoid (like a disk) admitted to the maternity unit with a
to a globular (like a globe) shape. The client suspected diagnosis of abruptio placentae.
may experience vaginal fullness, but not Which of the following assessment findings
severe uterine cramping. I am going to look would the nurse expect to note if this
more into this answer. According to our book condition is present?
on page 584, this is not one of our options.
[Link] of abdominal pain
A nurse in the labor room is performing a 2.A soft abdomen
vaginal assessment on a pregnant client in [Link] tenderness/pain
labor. The nurse notes the presence of the [Link], bright red vaginal bleeding
umbilical cord protruding from the vagina.
Which of the following would be the initial 3. In abruptio placentae, acute abdominal
nursing action? pain is present. Uterine tenderness and pain
accompanies placental abruption, especially
[Link] the client in Trendelenburg's position with a central abruption and trapped blood
[Link] the delivery room to notify the staff behind the placenta. The abdomen will feel
that the client will be transported hard and boardlike on palpation as the blood
immediately penetrates the myometrium and causes
[Link] push the cord into the vagina uterine irritability. Observation of the fetal
[Link] the closest telephone and stat page monitoring often reveals increased uterine
the physician resting tone, caused by failure of the uterus
to relax in attempt to constrict blood vessels
1. When cord prolapse occurs, prompt and control bleeding.
actions are taken to relieve cord
compression and increase fetal oxygenation. A maternity nurse is preparing for the
The mother should be positioned with the admission of a client in the 3rd trimester of
hips higher than the head to shift the fetal pregnancy that is experiencing vaginal
presenting part toward the diaphragm. The bleeding and has a suspected diagnosis of
placenta previa. The nurse reviews the A client is admitted to the birthing suite in
physician's orders and would question which early active labor. The priority nursing
order? intervention on admission of this client would
be:
[Link] the client for an ultrasound
[Link] equipment for external electronic [Link] the fetal heart
fetal heart monitoring [Link] an obstetric history
[Link] equipment for a manual pelvic [Link] the client when she last ate
examination [Link] whether the membranes were
[Link] to draw a Hgb and Hct blood ruptured
sample
3. Manual pelvic examinations are
contraindicated when vaginal bleeding is
apparent in the 3rd trimester until a
diagnosis is made and placental previa is
ruled out. Digital examination of the cervix 1. Determining the fetal well-being
can lead to maternal and fetal hemorrhage. supersedes all other measures. If the FHR is
A diagnosis of placenta previa is made by absent or persistently decelerating,
ultrasound. The H/H levels are monitored, immediate intervention is required.
and external electronic fetal heart rate
monitoring is initiated. External fetal A client who is gravida 1, para 0 is admitted
monitoring is crucial in evaluating the fetus in labor. Her cervix is 100% effaced, and she
that is at risk for severe hypoxia is dilated to 3 cm. Her fetus is at +1 station.
The nurse is aware that the fetus' head is:
An ultrasound is performed on a client at
term gestation that is experiencing moderate [Link] yet engaged
vaginal bleeding. The results of the [Link] the pelvic inlet
ultrasound indicate that an abruptio placenta [Link] the ischial spines
is present. Based on these findings, the [Link] at the vaginal opening
nurse would prepare the client for:
3. A station of +1 indicates that the fetal
[Link] bed rest for the remainder of the head is 1 cm below the ischial spines.
pregnancy
[Link] of the fetus After doing Leopold's maneuvers, the nurse
[Link] monitoring of intake and output determines that the fetus is in the ROP
[Link] need for weekly monitoring of position. To best auscultate the fetal heart
coagulation studies until the time of delivery tones, the Doppler is placed:

2. The goal of management in abruptio [Link] the umbilicus at the midline

placentae is to control the hemorrhage and [Link] the umbilicus on the left side
deliver the fetus as soon as possible. [Link] the umbilicus on the right side
Delivery is the treatment of choice if the [Link] the umbilicus near the left groin
fetus is at term gestation or if the bleeding is
moderate to severe and the mother or fetus 3. Fetal heart tones are best auscultated
is in jeopardy. through the fetal back; because the position
is ROP (right occiput presenting), the back
A nurse in a labor room is assisting with the would be below the umbilicus and on the
vaginal delivery of a newborn infant. The right side.
nurse would monitor the client closely for the
risk of uterine rupture if which of the The physician asks the nurse the frequency
following occurred? of a laboring client's contractions. The nurse
assesses the client's contractions by timing
[Link] contractions from the beginning of one contraction:
[Link] delivery
[Link] delivery [Link] the time it is completely over
[Link] bearing down efforts [Link] the end of a second contraction
[Link] the beginning of the next contraction
2. Excessive fundal pressure, forceps [Link] the time that the uterus becomes
delivery, violent bearing down efforts, very firm
tumultuous labor, and shoulder dystocia can
place a woman at risk for traumatic uterine 3. This is the way to determine the frequency
rupture. Hypotonic contractions and weak of the contractions
bearing down efforts do not alone add to the
risk of rupture because they do not add to The nurse observes the client's amniotic fluid
the stress on the uterine wall. and decides that it appears normal, because
it is:
[Link] and dark amber in color A laboring client complains of low back pain.
[Link], greenish yellow, containing shreds of The nurse replies that this pain occurs most
mucus when the position of the fetus is:
[Link], almost colorless, and containing
little white specks [Link]
[Link], greenish-yellow, and containing [Link]
little white specks [Link] anterior
[Link] posterior
3. by 36 weeks' gestation, normal amniotic
fluid is colorless with small particles of vernix
caseosa present.

At 38 weeks' gestation, a client is having late 4. A persistent occiput-posterior position

decelerations. The fetal pulse oximeter causes intense back pain because of fetal
shows 75% to 85%. The nurse should: compression of the sacral nerves. Occiput
anterior is the most common fetal position
[Link] the catheter, if the reading is and does not cause back pain.
not above 80%
[Link] the catheter, if the reading The breathing technique that the mother
does not go below 30% should be instructed to use as the fetus'
[Link] the catheter until the reading is head is crowning is:
above 90% and continue monitoring
[Link] the catheter, recheck the [Link]
reading, and if it is 55%, keep monitoring [Link] chest
[Link]
4. Adjusting the catheter would be indicated. [Link]-decelerated
Normal fetal pulse oximetry should be
between 30% and 70%. 75% to 85% would 1. Blowing forcefully through the mouth
indicate maternal readings. controls the strong urge to push and allows
for a more controlled birth of the head.
When examining the fetal monitor strip after
rupture of the membranes in a laboring During the period of induction of labor, a
client, the nurse notes variable decelerations client should be observed carefully for signs
in the fetal heart rate. The nurse should: of:

[Link] the oxytocin infusion [Link] pain

[Link] the client's position [Link] tetany
[Link] for immediate delivery [Link]
[Link] the client's blood pressure [Link] cord prolapsed

2. Variable decelerations usually are seen as 2. Uterine tetany could result from the use of
a result of cord compression; a change of oxytocin to induce labor. Because oxytocin
position will relieve pressure on the cord. promotes powerful uterine contractions,
uterine tetany may occur. The oxytocin
When monitoring the fetal heart rate of a infusion must be stopped to prevent uterine
client in labor, the nurse identifies an rupture and fetal compromise.
elevation of 15 beats above the baseline rate
of 135 beats per minute lasting for 15
seconds. This should be documented as:

[Link] acceleration
[Link] early elevation
3.A sonographic motion
4.A tachycardic heart rate

1. An acceleration is an abrupt elevation

above the baseline of 15 beats per minute
for 15 seconds; if the acceleration persists
for more than 10 minutes it is considered a
change in baseline rate. A tachycardic FHR is
above 160 beats per minute