Chapter 16 Flashcards
- A new mother asks the nurse when the “soft spot” on her son’s head will go away. What is the nurse’s best response, based upon her understanding of when the anterior frontal closes?
a. 2 months
b. 8 months
c. 12 months
d. 18 months
ANS: D
The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. The posterior fontanel closes at 6 to 8 weeks. The remaining three options are too early for the anterior fontanel to close.
- The nurse is performing an initial assessment of a client in labor. What is the appropriate terminology for the relationship of the fetal body parts to one another?
a. Lie
b. Presentation
c. Attitude
d. Position
ANS: C
Attitude is the relationship of the fetal body parts to one another. Lie is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother’s pelvis.
- When assessing the fetus using Leopold’s maneuvers, the nurse feels a round, firm, and movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother’s right side close to midline. What is the position of the fetus?
a. ROA
b. LSP
c. RSA
d. LOA
ANS: C
Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or the left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relationship to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother’s right side denotes the location of the presenting part in the mother’s pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is anteriorly positioned in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is anteriorly positioned in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is posteriorly positioned in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be anteriorly positioned in the left side of the pelvis with the occiput as the presenting part.
- Which statement by the client would lead the nurse to believe that labor has been established?
a. “I passed some thick, pink mucus when I urinated this morning.”
b. “My bag of waters just broke.”
c. “The contractions in my uterus are getting stronger and closer together.”
d. “My baby dropped, and I have to urinate more frequently now.”
ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Although the loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor; however, it is not an indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor but is not the indicator of true labor.
- The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?
a. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
b. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
c. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
d. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.
ANS: B
The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. The first interpretation of this vaginal examination is incorrect; the cervix is dilated 3 cm and is 30% effaced. However, the presenting part is correct at 2 cm above the ischial spines. The remaining two interpretations of this vaginal examination are incorrect. Although the dilation and effacement are correct at 3 cm and 30%, the presenting part is actually 2 cm above the ischial spines.
- A pregnant woman is at 38 weeks of gestation. She wants to know whether there are any signs that “labor is getting close to starting.” Which finding is an indication that labor may begin soon?
a. Weight gain of 1.5 to 2 kg (3 to 4 lb)
b. Increase in fundal height
c. Urinary retention
d. Surge of energy
ANS: D
Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, as a result of water loss caused by electrolyte shifts that, in turn, are caused by changes in the estrogen and progesterone levels. When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor.
- Which stage of labor varies the most in length?
a. First
b. Second
c. Third
d. Fourth
ANS: A
The first stage of labor is considered to last from the onset of regular uterine contractions to the full dilation of the cervix. The first stage is significantly longer than the second and third stages combined. In a first-time pregnancy, the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts approximately 2 hours after the delivery of the placenta.
- The nurse expects which maternal cardiovascular finding during labor?
a. Increased cardiac output
b. Decreased pulse rate
c. Decreased white blood cell (WBC) count
d. Decreased blood pressure
ANS: A
During each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system, which increases cardiac output by approximately 10% to 15% during the first stage of labor and by approximately 30% to 50% in the second stage of labor. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by approximately 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg.
- What is the correct term describing the slight overlapping of cranial bones or shaping of the fetal head during labor?
a. Lightening
b. Molding
c. Ferguson reflex
d. Valsalva maneuver
ANS: B
Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mother’s sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after the stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor.
- Which presentation is accurately described in terms of both the resenting part and the frequency of occurrence?
a. Cephalic: occiput, at least 96%
b. Breech: sacrum, 10% to 15%
c. Shoulder: scapula, 10% to 15%
d. Cephalic: cranial, 80% to 85%
ANS: A
In cephalic presentations (head first), the presenting part is the occiput; this presentation occurs in 96% of births. In a breech birth, the sacrum emerges first; this presentation occurs in approximately 3% of births. In shoulder presentations, the scapula emerges first; this presentation occurs in only 1% of births. In a cephalic presentation, the part of the head or cranium that emerges first is the occiput; cephalic presentations occur in 96% of births.
- A labor and delivery nurse should be cognizant of which information regarding how the fetus moves through the birth canal?
a. Fetal attitude describes the angle at which the fetus exits the uterus.
b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother.
c. Normal attitude of the fetus is called general flexion.
d. Transverse lie is preferred for vaginal birth.
ANS: C
The normal attitude of the fetus is called general flexion. The fetal attitude is the relationship of the fetal body parts to each one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie, the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie.
- A woman’s position is an important component of the labor progress. Which guidance is important for the nurse to provide to the laboring client?
a. The supine position, which is commonly used in the United States, increases blood flow.
b. The laboring client positioned on her hands and knees (“all fours” position) is hard on the woman’s back.
c. Frequent changes in position help relieve fatigue and increase the comfort of the laboring client.
d. In a sitting or squatting position, abdominal muscles of the laboring client will have to work harder.
ANS: C
Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The “all fours” position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions.
- Certain changes stimulate chemoreceptors in the aorta and carotid bodies to prepare the fetus for initiating respirations immediately after birth. Which change in fetal physiologic activity is not part of this process?
a. Fetal lung fluid is cleared from the air passages during labor and vaginal birth.
b. Fetal partial pressure of oxygen (PO2) decreases.
c. Fetal partial pressure of carbon dioxide in arterial blood (PaCO2) increases.
d. Fetal respiratory movements increase during labor.
ANS: D
Fetal respiratory movements actually decrease during labor. Fetal lung fluid is cleared from the air passages during labor and vaginal birth. Fetal PO2 decreases, and fetal PaCO2 increases.
- Which description of the four stages of labor is correct for both the definition and the duration?
a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours
b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours
c. Third stage: active pushing to birth; 20 minutes (multiparous woman), 50 minutes (nulliparous woman)
d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour
ANS: A
Full dilation may occur in less than 1 hour, but in first-time pregnancies full dilation can take up to 20 hours. The second stage of labor extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage of labor extends from birth to the expulsion of the placenta and usually takes a few minutes. The fourth stage begins after the expulsion of the placenta and lasts until homeostasis is reestablished (approximately 2 hours).
- Nurses should be cognizant of what regarding the mechanism of labor?
a. Seven critical movements must progress in a more or less orderly sequence.
b. Asynclitism is sometimes achieved by means of the Leopold’s maneuver.
c. Effects of the forces determining descent are modified by the shape of the woman’s pelvis and the size of the fetal head.
d. At birth, the baby is said to achieve “restitution”; that is, a return to the C-shape of the womb.
ANS: C
The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor simultaneously occur in combinations, not in precise sequences. Asynclitism is the deflection of the baby’s head; the Leopold’s maneuver is a means of judging descent by palpating the mother’s abdomen. Restitution is the rotation of the baby’s head after the infant is born.