Chapter 19 Flashcards
- Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor?
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. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.
- When a nulliparous woman telephones the hospital to report that she is in labor, what guidance should the nurse provide or information should the nurse obtain?
a. Tell the woman to stay home until her membranes rupture.
b. Emphasize that food and fluid intake should stop.
c. Arrange for the woman to come to the hospital for labor evaluation.
d. Ask the woman to describe why she believes she is in labor.
ANS: D
Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data. The initial nursing activity should be to gather data about the woman’s status. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular. Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.
- The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication?
a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension
ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of the contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.
- The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next?
a. Immediately notify the woman’s primary health care provider.
b. Prepare to administer an oxytocic to stimulate uterine activity.
c. Document the findings because they reflect the expected contraction pattern for the active phase of labor.
d. Prepare the woman for the onset of the second stage of labor.
ANS: C
The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse documents these findings in the client’s medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.
- Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions?
a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips
b. Determining the frequency by timing from the end of one contraction to the end of the next contraction
c. Evaluating the intensity by pressing the fingertips into the uterine fundus
d. Assessing uterine contractions every 30 minutes throughout the first stage of labor
ANS: C
The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus, which may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.
- When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?
a. Dilation of the cervix
b. Descent of the fetus to –2 station
c. Rupture of the amniotic membranes
d. Increase in bloody show
ANS: A
The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor, indicates that the woman is in true labor. Engagement and descent of the fetus are not synonymous and may occur before labor. ROM may occur with or without the presence of labor. Bloody show may indicate a slow, progressive cervical change (e.g., effacement) in both true and false labor.
- The nurse performs a vaginal examination to assess a client’s labor progress. Which action should the nurse take next?
a. Perform an examination at least once every hour during the active phase of labor.
b. Perform the examination with the woman in the supine position.
c. Wear two clean gloves for each examination.
d. Discuss the findings with the woman and her partner.
ANS: D
The nurse should discuss the findings of the vaginal examination with the woman and her partner, as well as report the findings to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned so as to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.
- A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse’s highest priority in this situation?
a. Prepare the woman for imminent birth.
b. Notify the woman’s primary health care provider.
c. Document the characteristics of the fluid.
d. Assess the fetal heart rate (FHR) and pattern.
ANS: D
The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the ROM to ascertain fetal well-being, and the findings should be documented. The ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary health care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse’s priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.
- Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position?
a. Occiput of the fetus is in a posterior position.
b. Fetus is at or above the ischial spines.
c. Fetus is in a vertex presentation.
d. Membranes have ruptured.
ANS: A
The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position. Many women experience the irresistible urge to push when the fetus is at the level of the ischial spines. In some cases, this urge is felt before the woman is fully dilated. The woman should be instructed not to push until complete cervical dilation has occurred. No one position is correct for childbirth. The two most common positions assumed by women are the sitting and side-lying positions. The woman may be encouraged into a hands-and-knees position if the umbilical cord prolapsed when the membranes ruptured.
- A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior?
a. A nulliparous woman will experience a strong urge to bear down.
b. Perineal bulging will show.
c. A nulliparous woman will remain quiet with her eyes closed between contractions.
d. The amount of bright red bloody show will increase.
ANS: C
The woman is able to relax and close her eyes between contractions as the fetus passively descends. The woman may be very quiet during this phase. During the latent phase of the second stage of labor, the urge to bear down is often absent or only slight during the acme of the contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor.
- Which clinical finding indicates that the client has reached the second stage of labor?
a. Amniotic membranes rupture.
b. Cervix cannot be felt during a vaginal examination.
c. Woman experiences a strong urge to bear down.
d. Presenting part of the fetus is below the ischial spines.
ANS: C
During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. The ROM has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting fetal part is below the level of the ischial spines. This urge can occur during the first stage of labor, as early as with 5 cm dilation.
- Through a vaginal examination, the nurse determines that a woman is 4 cm dilated. The external fetal monitor shows uterine contractions every to 4 minutes. The nurse reports this as what stage of labor?
a. First stage, latent phase
b. First stage, active phase
c. First stage, transition phase
d. Second stage, latent phase
ANS: B
This maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes. During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of “laboring down.”
- What is the most critical nursing action in caring for the newborn immediately after the birth?
a. Keeping the airway clear
b. Fostering parent-newborn attachment
c. Drying the newborn and wrapping the infant in a blanket
d. Administering eye drops and vitamin K
ANS: A
The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The care given immediately after birth focuses on assessing and stabilizing the newborn. The nursing activities are (in order of importance) to maintain a patent airway, to support respiratory effort, and to prevent cold stress by drying the newborn and covering him or her with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborn’s physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the newborn to the partner or to the mother of the infant.
- What is the rationale for the administration of an oxytocic (e.g., Pitocin, Methergine) after expulsion of the placenta?
a. To relieve pain
b. To stimulate uterine contraction
c. To prevent infection
d. To facilitate rest and relaxation
ANS: B
Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain, do not prevent infection, and do not facilitate rest and relaxation.
- Which description of the phases of the first stage of labor is most accurate?
a. Latent: mild, regular contractions; no dilation; bloody show
b. Active: moderate, regular contractions; 4 to 7 cm dilation
c. Lull: no contractions; dilation stable
d. Transition: very strong but irregular contractions; 8 to 10 cm dilation
ANS: B
The active phase is characterized by moderate and regular contractions, 4 to 7 cm dilation, and duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate and irregular contractions, dilation up to 3 cm, brownish-to-pale pink mucus, and duration of 6 to 8 hours. No official “lull” phase exists in the first stage. The transition phase is characterized by strong to very strong and regular contractions, 8 to 10 cm dilation, and duration of 20 to 40 minutes.
- Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand?
a. Client is considered to be in active labor when she arrives at the facility with contractions.
b. Client can have only her male partner or predesignated doula with her at assessment.
c. Children are not allowed on the labor unit.
d. Non–English speaking client must bring someone to translate.
ANS: A
According to the Emergency Medical Treatment and Active Labor Act (EMTALA), a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise. A woman may have anyone she wishes present for her support. An interpreter must be provided by the hospital, either in person or by a telephonic service. Siblings of the new infant may be allowed at the delivery, depending on hospital policy and adequate preparation and supervision.
- Which component of the physical examination are Leopold’s maneuvers unable to determine?
a. Gender of the fetus
b. Number of fetuses
c. Fetal lie and attitude
d. Degree of the presenting part’s descent into the pelvis
ANS: A
Leopold’s maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus cannot be determined by performing Leopold’s maneuvers.
- Where is the point of maximal intensity (PMI) of the FHR located?
a. Usually directly over the fetal abdomen
b. In a vertex position, heard above the mother’s umbilicus
c. Heard lower and closer to the midline of the mother’s abdomen as the fetus descends and internally rotates
d. In a breech position, heard below the mother’s umbilicus
ANS: C
Nurses should be prepared for the shift. The PMI of the FHR is usually directly over the fetal back. In a vertex position, the PMI of the FHR is heard below the mother’s umbilicus. In a breech position, it is heard above the mother’s umbilicus.
- The nurse should be aware of which information related to a woman’s intake and output during labor?
a. Traditionally, restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia.
b. Intravenous (IV) fluids are usually necessary to ensure that the laboring woman stays hydrated.
c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery.
d. When a nulliparous woman experiences the urge to defecate, it often means birth will quickly follow.
ANS: A
Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. The routine use of an enema is, at best, ineffective and may be harmful. Having the urge to defecate followed by the birth of her fetus is true for a multiparous woman but not for a nulliparous woman.
- Which technique is an adequate means of controlling the birth of the fetal head during delivery in a vertex presentation?
a. Ritgen maneuver
b. Fundal pressure
c. Lithotomy position
d. De Lee apparatus
ANS: A
The Ritgen maneuver extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth. The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider. The De Lee apparatus is used to suction fluid from the infant’s mouth.
- Which collection of risk factors will most likely result in damaging lacerations, including episiotomies?
a. Dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife
b. Reddish-haired mother of two who is going through a breech birth
c. Dark-skinned first-time mother who is going through a long labor
d. First-time mother with reddish hair whose rapid labor was overseen by an obstetrician
ANS: D
Reddish-haired women have tissue that is less distensible than darker-skinned women and therefore may have less efficient healing. First-time mothers are also at greater risk, especially with breech births, long second-stage labors, or rapid labors during which the time for the perineum to stretch is insufficient. The rate of episiotomies is higher when obstetricians rather than midwives attend the births. The woman in the first scenario (a) is at low risk for either damaging lacerations or an episiotomy. She is multiparous, has dark skin, and is being attended by a midwife, who is less likely to perform an episiotomy. Reddish-haired women have tissue that is less distensible than that of darker-skinned women. Consequently, the client in the second scenario (b) is at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy. The fact that the woman in the third scenario (c) is experiencing a prolonged labor might increase her risk for lacerations. Fortunately, she is dark skinned, which indicates that her tissue is more distensible than that of fair-skinned women and therefore less susceptible to injury.