Flashcards in Lecture 1 Labor and birth Deck (28):
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 fontanel closes?
18 months. [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 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?
Attitude. [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?
RSA. [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.]
The contraction urge of the uterus after the stimulation of the cervix. As the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs. Leads to *secondary powers* - the urge to bear down.
Nurses should be cognizant of what regarding the mechanism of labor?
Effects of the forces determining descent are modified by the shape of the woman’s pelvis and the size of the fetal head. [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.]
Largest and smallest diameters of the presenting part
The largest diameter is usually the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical.
Which statement is the best rationale for assessing the maternal vital signs between uterine contractions?
Maternal circulating blood volume temporarily increases during contractions. [During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother’s blood volume, which, in turn, temporarily increases blood pressure and slows the pulse.]
Ideal arrangement of the fetus during delivery
Vertex (presentation) with flexion (attitude) in an occipitoanterior orientation. (Lie is longitudinal.)
Stretch receptors in the posterior vagina cause release of endogenous _ that triggers the maternal urge to bear down.
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?
Document the findings because they reflect the expected contraction pattern for the active phase of 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?
Evaluating the intensity by pressing the fingertips into the uterine fundus. [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.]
When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?
Dilation of the cervix. [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.]
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?
Assess the fetal heart rate (FHR) and pattern. [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.]
A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior?
A nulliparous woman will remain quiet with her eyes closed between contractions. [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.]
Which clinical finding indicates that the client has reached the second stage of labor?
Dilation of the cervix to 10 cm.
In order of importance, the nursing actions required in the care of the newborn immediately after birth are _
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?
To stimulate uterine contraction. [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.]
Where is the point of maximal intensity (PMI) of the FHR located?
Heard lower and closer to the midline of the mother’s abdomen as the fetus descends and internally rotates. [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.]
Apgar score - timing
At 1 minute and at 5 minutes after birth.
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. What is the primary purpose of this activity?
To stimulate the uterus to contract. [Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.]
The main determinant of true labor vs. false labor is _
pH test for whether ROM has occurred - pH of 6 or below indicates that the membranes are probably intact; a pH of 6.5 or above indicates that the membranes have probably ruptured (amniotic fluid has an alkaline pH).
Which statement related to fetal positioning during labor is correct and important for the nurse to understand?
Birth is imminent when the presenting part is at +4 to +5 cm below the spine. [The station of the presenting part should be noted at the beginning of labor to determine the rate of descent. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother’s pelvis; station is the measure of degree of descent. The largest diameter is usually the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparous women and before or during labor in multiparous women.]
The classic female pelvic shape, slightly ovoid and rounded; approximately 50% of women have this shape.
A malelike pelvic shape, heart shaped; approximately 23% of women have this shape.
An apelike pelvic shape, oval and wide; approximately 24% of women have this shape.
Flattened, wide, and shallow; approximately 3% of women have this shape.