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Labor and delivery
Terms in this set (36)
A woman who is 38 weeks pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more
How do Braxton-Hicks contractions, which may begin in the first trimester and become increasingly stronger during the pregnancy, differ from labor contractions?
Do not dilate the cervix
Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can
range from mild to moderate in severity, and increase in duration as the pregnancy progresses.
When trying to differentiate false labor from true labor, the nurse realizes which of the following statements regarding true labor is correct?
Contractions get stronger with ambulation.
Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of
regular, rhythmic contractions
Why is the size and shape of the true pelvis more important than that of the false pelvis?
The fetal head must be able to pass through the true pelvis.
The size and shape of the true pelvis is more important than the false pelvis because the fetal head
must be able to pass through for vaginal delivery to occur.
What method is used to visualize soft tissue and to determine adequacy of the pelvis with no detrimental effects to the fetus?
In more than 20 years of use, ultrasonography has had no detrimental effects on the fetus. Pelvimetry and x-ray uses radiation to visualize bony prominences. Pelvimetry is not used in the pregnant patient due to detrimental effects to the fetus. Palpation does not allow for visualization of soft tissue.
What area of the uterus provides the force during a contraction?
The upper portion of the uterus provides the force during contractions.
What is the largest diameter of the fetal skull?
The largest transverse diameter of the fetal skull is the biparietal measurement. If this is too large, the
skull may not be able to enter the mothers pelvis.
A nurse is teaching a group of primigravidas that during delivery, pressure on the fetal skull may produce changes in the shape of the skull. What is the reshaping of the skull called?
What is the ideal attitude for the fetal body during labor?
Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus. How should the nurse document the fetal position?
Right occiput anterior (ROA), vertex
Fetal position can be determined by the Leopold maneuver, which defines the relationship of the presenting part to the maternal pelvis quadrant. A soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus indicate a right occiput anterior (ROA), vertex positioning.
During the second stage of labor, how often should the nurse should monitor the fetal heart rate?
Every 5 minutes
Which type of monitor will assesses the intensity of contractions?
Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity.
When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 bpm at the beginning of a contraction and returns to a baseline of 155 bpm at the end of the contraction. What should this indicate to the nurse?
Early deceleration due to head compression
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
A backrub in the sacral area
Backache in the sacral area is a common complaint during the first stage of labor. The keyword is
comfort in the question. Providing a backrub is providing comfort to the laboring patient.
A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 bpm. What action should the nurse take based on the assessment?
Reassure the mother the rate is normal
The normal FHR is 120 to 160 bpm. No interventions are required.
.The patients membranes have just ruptured. What is the first priority of the nurse?
Check the fetal heart rate (FHR)
The FHR should be assessed immediately after rupture of the membranes to determine the well-being
of the baby.
A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
The cervix has softened and effaced
One sign of true labor is when the cervix has softened and effaced. True labor contractions are
regular and rhythmic.
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take?
Place the patient in the knee-chest position
The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse will need to be notified, and the contractions will need to be monitored. However, the priority is reducing the pressure on the prolapsed cord.
.A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
Correctly identifying abnormal FHR patterns and notifying the health care provider
Nurses are responsible for the timely notification of the primary caregiver in the event of an
abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order.
A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when?
The cervix is fully dilated
The first stage of labor begins with regular contractions and ends with complete dilation of the
The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment, which assessment is the priority?
The timing of contractions
Assessment begins with timing the contractions on admission to form a database.
During labor, the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
Assure the husband that such behavior is normal
A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. Which statement is true?
The widest diameter of the presenting part crosses the pelvic inlet.
Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet.
The physician has decided to induce labor with prostaglandin gel and an amniotomy. When should the nurse expect that labor will start?
Medically approved methods of inducing labor include prostaglandin gel application that usually
induces labor in 1 hour or less.
A mother has entered the second stage of labor. When does the second stage of labor end?
With delivery of the baby
The second stage of labor begins with complete dilation and ends with the birth of the baby.
Why is oxytocin administered in the third stage of labor?
To stimulate uterine contractions
Oxytocin makes the uterus contract and reduces postpartum hemorrhage.
After the delivery of a newborn, what is the priority action of the nurse?
Suction nose and mouth
To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent
An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar score should be assigned to this infant?
The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2;
pink body, blue limbs = 1
For the first hour following delivery, how often should the nurse assess the mother?
Every 15 minutes
When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured, the paper turns yellow. What does this finding indicate?
Acidic discharge, membranes intact
In the illustration below, which item depicts the LOT position?
The LOT position is left occiput transverse.PTS: 1 DIF: Cognitive Level: Analysis REF: Page 803, Figure 26-5OBJ:7TOP:Fetal positionKEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
Which assessment findings suggest probable fetal distress? (Select all that apply.)
Meconium-stained amniotic fluid
Slow return of FHR to baseline
Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are indicative of
fetal distress. All other options are normal.
A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center? (Select all that apply.)
The patient will be having a planned cesarean delivery
The mother has preeclampsia.
Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mothers support system would not be factors considered when determining risk for delivering in a birthing center.
The nurse explains to the patient whose membranes ruptured an hour ago that delivery is usually accomplished in ____ to _____ hours postrupture.
After the rupture of membranes, labor is usually accomplished in 18 to 24 hours.
A primigravida has a pelvis of the android type, which usually means the delivery will be a _______________.
The narrow outlet of the android-type pelvis usually requires a cesarean delivery.
A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mothers to demonstrate a ________ lie.
A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other.
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