ANS: A Show PTS: 1 DIF: Cognitive Level: Comprehension Sets found in the same folderRecommended textbook solutions
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Terms in this set (52)B,C,E There are "five P's" that affect the labor process. They are passageway, passenger, powers, position, and psychological response. There are an additional five that can also have an effect on the labor process. They include philosophy, partners, patience, client preparation, and pain control. Sets with similar termsSets found in the same folderOther sets by this creatorRecommended textbook solutions
Other Quizlet setsRelated questionsA woman who has had 2 spontaneous abortions at 12 weeks gestation, has a 3 year old son, and is now 32 weeks pregnant would have a GTPAL described as? A. G2, T1, P0, A2, L1 Sets found in the same folderUpgrade to remove ads Only ₩37,125/year
Terms in this set (75)When determining the frequency of contractions, the nurse would measure which of the following? A. Start of one contraction to the start of the next contraction Which fetal lie is most conducive to a spontaneous vaginal birth? B. Longitudinal Which of the following observations would suggest that placental separation
is occurring? C. Uterine shape changes to globular. As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: B. Progressive cervical changes occur in true labor. The shortest but most intense phase of labor is the: C. Transition phase A laboring woman is admitted to the labor and birth suite at 6 cm dilation. She would be in which phase of the first stage of labor? B. Active Which assessment would indicate that a woman is in true labor? C. Cervix is 4cm dilated, 90% effaced. Interventions that are underutilized in promoting a normal birth. Select all that apply. A. Oral nutrition and fluids in labor Physiologic preparation for labor would be demonstrated by: C. Lightening, whereby the fetus drops into true pelvis When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? D. Wait until you feel the urge to push. During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? B. Uterine fundus palpated to the right of the umbilicus When managing a client's pain during labor, nurses should: C. Support the client's decisions and requests When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: A. 15 to 30 minutes The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? C. Document this as indicating a normal pattern. By the end of the second stage of labor, the nurse would expect which of the following events? The C. Fetus is born and on mother's chest Which of the following practices would not be included in a physiologic birth? A. Early induction of labor <39 weeks' gestation When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal
pelvis. The nurse interprets this as: D. Fetopelvic disproportion After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have: A. Intense back pain The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: D. Soften and efface the cervix A
client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: C. Hypotonic labor The nurse is developing a plan of care for a woman experiencing dystocia.
Which of the following nursing interventions would be the nurse's high priority? C. Monitoring the fetal heart rate patterns The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's
contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: B. Provide pain relief measures The nurse is caring for a client in labor. Which assessment findings indicate to the nurse
that the client is beginning the second stage of labor? Select all that apply. C. The cervix is dilated completely The
nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? A. Administer oxygen via face mask The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? B. Fetal heart rate of 180 beats/minute A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station . The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. C. Increased efficiency of contractions The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is
noted on the external monitor tracing during a contraction? D. Variable decelerations A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? A. Supine position with a wedge under the right hip The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the
fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? A. Notify the heathy care provider (HCP) The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitoring tracing. Which action is most appropriate? D. Document the findings and tell the mother that the pattern on the monitor indicated fetal well-being The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, that
is the next nursing action? B. Assess the baseline fetal heart rate The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor is she makes
which statement? D. "My contractions will increase in duration and intensity" Which assessment following an amniotomy should be conducted first? C. Fetal heart rate pattern The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? B. Rest between contractions The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? B. Discontinue the infusion of oxytocin An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the
basis of these findings, the nurse should prepare the client for which anticipated prescription? A. Delivery of the fetus The nurse in a birthing room is monitoring a client with dysfunctional
labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? D. Persistent nonreassuring fetal heart rate A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse
is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? A. Provide pain relief measures The nurse is reviewing the health care provider's
prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? C. Performs a vaginal examination every shift The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? B. Monitoring the fetal heart rate Fetal
distress is occurring with a laboring client. As the nurse prepares the client for cesarean birth, what is the most important nursing action? D. Administer oxygen 8 to 10 L/minute, via face mask The nurse in a labor room is
performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? B. Place the client in Trendelenburg position The nurse performs a vaginal examination and determines that the fetus is in a sacrum anterior position. The nurse should draw which conclusion from this assessment data? A. The fetal sacrum is toward the maternal symphysis pubis The client has been having contractions every five minutes for seven hours. Which factor should the nurse consider to determine if this is true labor? A. The cervix is showing a pattern of effacement and dilation Which intervention should be the highest priority of the nurse who is caring for the client who is in labor? D. Assessment of fetal response to the labor As labor progresses, the nurse should expect to assess that a client's contractions are developing which characteristics? B. More intense, more frequent, and of longer duration Which observation should indicate to the nurse that the client is exhibiting a sign of impending placental separation and expulsion? C. Small gush of blood with lengthening of the cord The nurse determines that a client in labor is exhibiting signs of increased anxiety. The nurse should anticipate that this may have which consequence to the client? B. Increased pain during the labor process Earlier in the day, the baseline fetal heart rate (FHR) on a client in labor's fetus was 140. It is now 170. The nurse should consider that which of the factors could be an explanation for this change? Select all that apply. A. Maternal fever The nurse should determine that teaching has been effective when a client who is in labor makes which statement? B. "My cervix will probably efface before it dilates, because this is my first pregnancy" The client's vagina examination reveals that the cervix is three centimeters dilated, 80% effaced, and position is vertex at zero station. The woman is talkative and appears excited. The nurse should interpret that the client is in which stage and phase of labor? A. First stage, latent phase Which client statements should indicate to the nurse that the client who is in labor needs further education? A. "Because this is my first labor, I will need an epidural" The nurse should formulate which general goal when developing childbirth education classes for pregnant women in the community? C. Assist clients to know what to expect during labor After performing a vaginal exam the nurse discussed the results with the client and her partner. The nurse later concludes that client teaching was effective when the partner shouts, "She must be crowning; this means it will be soon", after making which observation? C. The perineum is thin and stretching around the occiput The nurse notes on the antepartal history that the pregnant client has a android pelvis. The nurse should conclude that this client is at an
increased risk for which event? A. A prolonged labor The maternal newborn nurse should use which description of the fetal position when explaining to the mother the occurrence of a frank breech position? C. "The hips are flexed, and the knees are extended" The fetal head is determined to be presenting in a position of complete extension. The maternal newborn nurse should anticipate which type of labor and delivery? B. Prolonged labor and possible cesarean delivery The pregnant client is 7 cm dilated, 100% effaced, and at a +1 station. The fetus is in a vertex presentation. The nurse should conclude that client teaching has been effective when the client's husband makes which statements? Select all that apply. D. "Our baby will come out with the back of the head first" Following amniotomy, the nurse should carry out which interventions as important nursing
actions? Select all that apply. B. Place clean bedding and under pads on the bed A client's amniotic fluid is greenish-tinged and fetal presentation is vertex. Fetal heart rate (FHR) and uterine activity have remained within normal limits. At the time of delivery, the nurse should anticipate the need for which equipment? A. An infant laryngoscope and suction catheters A client who is 34 weeks gestation has been having contractions every 10 minutes regularly. In addition to instructing her to lie down and rest while continuing to time contractions, the nurse should also provide her with which instruction? D. Drink three to four cups of water Which statement by the nurse would be most therapeutic in talking with a client and her family following emergency cesarean birth? C. "You did so well during the delivery. I'm sorry I didn't have more time to explain things" The pregnant client is receiving oxytocin to induce labor. The nurse should monitor the client for which adverse maternal effects? Select all that apply. B. Decreased urine output A pregnant client is receiving a tocolytic drug to stop contractions and prevent premature labor. Which assessments should the nurse make to monitor for side or adverse drug effects in this client? Select all that apply. A. Lung sounds The nurse is monitoring a client during a vaginal delivery of a breech infant. Which adverse event should the nurse consider to be the greatest risk to the fetus during delivery? A. Umbilical cord prolapse A client who is multiparous and in labor for almost three hours suddenly announces that the baby is coming. The nurse sees the infant crowning. What should be the initial action by the nurse? A. Ask the woman to pant while preparing to place gentle counterpressure on the infant's head as it is delivered The nurse determines that a client has an understanding of the planned cesarean delivery when the client makes which statements? Select all that apply. A. "An indwelling urinary catheter will be inserted before surgery" The maternal newborn nurse notes a deceleration of the fetal heart rate from 130 to 70 beats per minute with contractions followed by a rapid return to a normal baseline rate. The nurse should conclude that this is most likely a response to which condition? A. Umbilical cord compression The nurse working with a client in labor should determine that fetal distress is occurring after noting which clinical sign? C. Meconium-stained amniotic fluid On performing Leopold maneuvers on a client who
is multiparous in early labor, the nurse finds no fetal parts in the fundus or above the symphysis. The fetal head is palpated in the right mid quadrant. The nurse notifies the admitting healthcare provider and should anticipate which event? C. A cesarean delivery The nurse discovers
a loop of umbilical cord protruding through the vagina when performing a vaginal examination on a client in labor. What should be the priority nursing intervention at this time? D. Continue with the vaginal examination, and apply upward digital pressure to the presenting part while having the mother assume a knee-chest position The client has refused sedation prescribed by the healthcare provider for hypertonic contractions and prolonged latent-phase labor for fear that her labor will stop. The nurse may help by providing which explanation to the
client? A. Sedation helps to provide needed rest and allows time for the uterine contractions to become coordinated so that labor is progressive The client is receiving intravenous magnesium sulfate at two grams/hr to stop premature labor. Which client assessments should the nurse determine to be most important to determine the presence of magnesium toxicity? C. Deep tendon reflexes, hourly urine output, and respiratory rate During augmentation of labor with intravenous oxytocin, a client who is multiparous becomes pale and diaphoretic and reports severe lower abdominal pain with a tearing sensation. Fetal
distress is noted on the monitor. What complication should the nurse expect? C. Rupture of the uterus During a vaginal examination on a pregnant client, the nurse palpated the fetal head and a large diamond-shaped fontanelle. The nurse should document which fetal presentation in the health record? D. Brow Sets with similar termsNCLEX on intrapartum84 terms athislee Intrapartum27 terms chelsie_dugay NCLEX on intrapartum75 terms andria_montgomery Sets found in the same folderN225_Family109 terms Lovdash3 Nursing Management of Pain During Labor and Birthhh102 terms sarahdemchenko Postpartum practice questions44 terms sriveralopez OB Exam 3 Questions103 terms ksende Other sets by this creatorNCLEX: Mark Klimek547 terms Katie_Farrell6 Nursing V: Unit 885 terms Katie_Farrell6 Nursing V: Unit 587 terms Katie_Farrell6 Nursing V: Unit 4101 terms Katie_Farrell6 Recommended textbook solutionsThe Human Body in Health and Disease7th EditionGary A. Thibodeau, Kevin T. Patton 1,505 solutions
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How are the frequency of contractions measured quizlet?Frequency is measured from the start of one contraction to the start of the next contraction. The duration of a contraction is measured from the beginning of one contraction to the end of that same contraction.
How do you measure duration of contractions?When timing contractions, start counting from the beginning of one contraction to the beginning of the next. The easiest way to time contractions is to write down on paper the time each contraction starts and its duration, or count the seconds the actual contraction lasts, as shown in the example below.
How should the nurse determine the frequency of uterine contraction quizlet?To determine the frequency of uterine contractions,the nurse should note the time from the: Beginning of one contraction to the beginning of the next contraction. Excessive anxiety and fear during labor may result in an: Ineffective labor pattern.
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When determining the frequency of contractions the nurse would measure which period of time quizlet?
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