Chapter 16: Labour and birth processes

Question 1

1. A new mother asks a nurse when the “soft spot” on their newborn’s head will go away. The nurse’s answer is based on the knowledge that the anterior fontanel closes how many months after birth?
   a. 2 months
   b. 8 months
   c. 12 months
   d. 18 months

Answer 1

ANS: D
The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.

Question 2

2. What is the term for the relationship of the fetal body parts to one another?
   a. Lie
   b. Presentation
   c. Attitude
   d. Position

Answer 2

ANS: C
Attitude is the relation of the fetal body parts to one another. Lie is the relation 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 labour at term. Position is the relation of the presenting part to the four quadrants of the mother’s pelvis.

Question 3

3. A nurse has received a report about a patient in labour. The patient’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?
   a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm
   above the ischial spines.
   b. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm
   above the ischial spines.
   c. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm
   below the ischial spines.
   d. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm
   below the ischial spines.

Answer 3

ANS: B
The correct description of the vaginal examination for this patient in labour is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimetres of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or belo w).

Question 4

4. Which position would a nurse be least likely to suggest for a labouring patient, when gravity is needed to assist in fetal descent?
   a. Lithotomy
   b. Kneeling
   c. Sitting
   d. Walking

Answer 4

ANS: A
Lithotomy position requires a patient to be in a reclined position with their legs in stirrups. Gravity has little effect in this position. Kneeling, sitting, and walking help align the fetus with the pelvic outlet and allow gravity to assist in fetal descent.

Question 5

5. Which position would the nurse suggest for second-stage labour if the pelvic outlet needs to be increased?
   a. Semirecumbent
   b. Sitting
   c. Squatting
   d. Semi-Fowler’s

Answer 5

ANS: C
The squatting position may help increase the pelvic outlet. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labour by increasing the pelvic outlet.

Question 6

6. To adequately care for a labouring woman, a nurse should know that which stage of labour varies most in length?
   a. First
   b. Second
   c. Third
   d. Fourth

Answer 6

ANS: A
The first stage of labour is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labour can take up to 18 hours or longer. The second stage of labour lasts from the time the cervix is fully dilated to the birth of the fetus and is relatively short. The third stage of labour lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 to 5 minutes or as long as 1 hour. The fourth stage of labour, recovery, lasts about 2 hours after delivery of the placenta.

Question 7

7. A nurse would expect which maternal cardiovascular finding during labour?
   a. Increased cardiac output
   b. Decreased pulse rate
   c. Decreased white blood cell (WBC) count
   d. Decreased blood pressure

Answer 7

ANS: A
During each contraction 400 mL of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 10% to 15% during the first stage of labour and by about 50% by the end of the first stage. The heart rate increases slightly during labour. The WBC count can increase during labour. During the first stage of labour uterine contractions cause systolic readings to increase by about 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.

Question 8

8. Which represents one of the factors that affect the process of labour and birth, known commonly as the five P’s?
   a. Pelvic diameters
   b. Position
   c. Powers
   d. Pressure

Answer 8

ANS: C
The five P’s are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychological response.

Question 9

9. A nurse is aware that what is the term for the slight overlapping of cranial bones or shaping of the fetal head during labour?
   a. Lightening
   b. Moulding
   c. Ferguson reflex
   d. Valsalva manoeuvre

Answer 9

ANS: B
Moulding permits adaptation to various diameters of the maternal pelvis. Lightening is the mother’s sensation of decreased abdominal distension, which usually occurs the week before labour. Fetal head formation is called moulding. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. The Valsalva manoeuvre describes conscious pushing during the second stage of labour.

Question 10

10. Which presentation is described accurately in terms of both presenting part and frequency of occurrence?
    a. Cephalic: occiput; at least 95%
    b. Breech: sacrum; 10% to 15%
    c. Shoulder: scapula; 10% to 15%
    d. Cephalic: cranial; 80% to 85%

Answer 10

ANS: A
In cephalic presentations (head first) the presenting part of the head or cranium is the occiput; this occurs in 96% of births. In a breech birth the sacrum emerges first; this occurs in about 3% of births. In shoulder presentations the scapula emerges first; this occurs in only 1% of births

Question 11

11. Which is true with regard to factors that affect how the fetus moves through the birth canal?
    a. The 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. The normal attitude of the fetus is called general flexion.
    d. The transverse lie is preferred for vaginal birth.

Answer 11

ANS: C
The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal body parts to 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.

Question 12

12. What should a nurse be aware of with regard to fetal positioning during labour?
    a. Position is a measure of the degree of descent of the presenting part of the fetus
    through the birth canal.
    b. Birth is imminent when the presenting part is at +4 to +5 cm, below the spine.
    c. The largest transverse diameter of the presenting part is the suboccipitobregmatic
    diameter.
    d. Engagement is the term used to describe the beginning of labour.

Answer 12

ANS: B
The station of the presenting part should be noted at the beginning of labour so that the rate of descent can be determined. Position is the relation 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 usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical measurements. Engagement often occurs in the weeks just before labour in nulliparas and before or during labour in multiparas.

Question 13

13. Which basic type of pelvis includes the correct description and percentage of occurrence in pregnant patients?
    a. Gynecoid: classic female; heart shaped; 75%
    b. Android: resembling the male; wider oval; 15%
    c. Anthropoid: resembling the ape; narrower; 10%
    d. Platypelloid: flattened, wide, shallow; 3%

Answer 13

ANS: D
A platypelloid pelvis is flattened, wide, and shallow; about 3% of patients have this shape. The gynecoid shape is the classical female shape, slightly ovoid and rounded; about 50% of patients have this shape. An android, or male-like, pelvis is heart shaped; about 23% of patients have this shape. An anthropoid, or apelike, pelvis is oval and wider; about 24% of patients have this shape.

Question 14

14. What should a nurse know with regard to primary and secondary powers?
    a. Primary and secondary powers are responsible for effacement and dilation of the
    cervix.
    b. Effacement generally is well ahead of dilation in patients giving birth for the first
    time; effacement and dilation are more together in subsequent pregnancies.
    c. Scarring of the cervix caused by a previous infection or surgery may make the
    birth a bit more painful, but it should not slow or inhibit dilation.
    d. Pushing in the second stage of labour is more effective if the patient can breathe
    deeply and control some of her involuntary needs to push, as the nurse directs.

Answer 14

ANS: B
Effacement generally is well ahead of dilation in first-timers; they are more together in subsequent pregnancies. The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the patient begins to push only after she has the urge to do so.

Question 15

15. What should a nurse teach a patient about their position during labour?
    a. The supine position increases blood flow.
    b. The “all fours” position, on hands and knees, is hard on the patient’s back.
    c. Frequent changes in position will help relieve fatigue and increase comfort.
    d. In a sitting or squatting position the abdominal muscles will have to work harder.

Answer 15

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.

Question 16

16. Which description of the four stages of labour is correct for both definition and duration?
    a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour
    to 18 hours
    b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours
    c. Third state: active pushing to birth; 20 minutes (multipara), 50 minutes
    (primipara)
    d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

Answer 16

ANS: A
Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is re-established (about 2 hours).

Question 17

17. What should a nurse be aware of with regard to the turns and other adjustments of the fetus during the birth process?
    a. The seven critical movements must progress in a more or less orderly sequence.
    b. Asynclitism sometimes is achieved by means of the Leopold manoeuvre.
    c. The effects of the forces determining descent are modified by the shape of the
    patient’s pelvis and the size of the fetal head.
    d. At birth the baby is said to achieve “restitution” (i.e., a return to the C-shape of
    the womb).

Answer 17

ANS: C
The size of the maternal pelvis and the ability of the fetal head to mould also affect the process. The seven identifiable movements of the mechanism of labour occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the baby’s head; the Leopold manoeuvre 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.

Question 18

18. What should a nurse be aware of to accurately assess the health of the mother during labour?
    a. The patient’s blood pressure will increase during contractions and fall back to
    prelabour normal between contractions.
    b. Use of the Valsalva manoeuvre is encouraged during the second stage of labour to
    relieve fetal hypoxia.
    c. Having the patient point their toes will reduce leg cramps.
    d. The endogenous endorphins released during labour will raise the patient’s pain
    threshold and produce sedation.

Answer 18

ANS: D
The endogenous endorphins released during labour will raise the woman’s pain threshold and produce sedation. In addition, physiological anaesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother’s perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva manoeuvre is discouraged during second-stage labour because it can lead to a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labour itself.

Question 19

19. A nurse teaches a pregnant patient that which may be a sign that precedes labour?
    a. Lightening
    b. Exhaustion
    c. Weight gain
    d. Decreased fetal movement

Answer 19

ANS: A
Signs that precede labour may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many patients experience a burst of energy before labour. A decrease in fetal movement is an ominous sign that does not always correlate with labour.

Question 20

20. A nurse is aware that which factor influences cervical dilation?
    a. The size of the fetus
    b. The diameters of the bony pelvis
    c. The size of the female
    d. The pressure applied by the amniotic sac

Answer 20

ANS: D
Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Fetal size does not affect dilation. Pelvic size does not affect cervical dilation. The diameters of the pelvis do not affect dilation

Question 21

21. When assessing the fetus using Leopold maneuvers, a nurse feels a round, firm, 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 likely position of the fetus?
    a. ROA
    b. LSP
    c. RSA d. LOA

Answer 21

ANS: C
The fetus is positioned anteriorly 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. The first letter indicates the presenting part in either the right or 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 relation 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 po sitioned in the maternal pelvis.

Question 22

22. The factors that affect the process of labor and birth, known commonly as the five Ps, include all except
    a. passenger.
    b. passageway.
    c. powers.
    d. pressure.

Answer 22

ANS: D
The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychological response

Question 23

23. A perinatal nurse understands that as the uterus contracts during labour, maternal-fetal exchange of oxygen and waste products
    a. continues except when placental functions are reduced.
    b. increases as blood pressure decreases.
    c. diminishes as the spiral arteries are compressed.
    d. is not significantly affected.

Answer 23

ANS: C
Uterine contractions during labour tend to decrease circulation through the spiral electrodes and subsequent perfusion through the intervillous space. The maternal blood supply to the placenta gradually stops with contractions. The exchange of oxygen and waste products decreases. The exchange of oxygen and waste products is affected by contractions.

Question 24

24. Which statement is the best rationale for assessing maternal vital signs between contractions?
    a. During a contraction, assessing fetal heart rates is the priority.
    b. Maternal circulating blood volume increases temporarily during contractions.
    c. Maternal blood flow to the heart is reduced during contractions.
    d. Vital signs taken during contractions are not accurate.

Answer 24

ANS: B
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 pulse. It is important to monitor fetal response to contractions; however, this question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction. Vital signs are altered by contractions but are considered accurate for that period of time.

Question 25

25. In order to care for obstetric patients adequately, a perinatal nurse understands that labour contractions facilitate cervical dilation by
    a. contracting the lower uterine segment.
    b. enlarging the internal size of the uterus.
    c. promoting blood flow to the cervix.
    d. pulling the cervix over the fetus and amniotic sac.

Answer 25

ANS: D
Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps to push the fetus down. Blood flow decreases to the uterus during a contraction.

Question 26

26. When teaching patients about the process of labour, a nurse explains that which event is the best indicator of true labour?
    a. Bloody show
    b. Cervical dilation and effacement
    c. Fetal descent into the pelvic inlet
    d. Uterine contractions every 7 minutes

Answer 26

ANS: B
The conclusive distinction between true and prelabour is that contractions of true labour cause progressive change in the cervix. Bloody show can occur before true labour. Fetal descent can occur before true labour. Prelabour may have contractions that occur this frequently; however, this is usually inconsistent.

Question 27

27. Which occurrence is associated with cervical dilation and effacement?
    a. Bloody show
    b. Prelabour
    c. Lightening
    d. Bladder distention

Answer 27

ANS: A
As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries. Cervical dilation and effacement do not occur with prelabor. Lightening is the descent of the fetus toward the pelvic inlet before labour. Bladder distention occurs when the bladder is not emptied frequently. It may slow down the descent of the fetus during labour.

Question 28

28. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the patient to be
    a. admitted and prepared for a Caesarean birth.
    b. admitted for extended observation.
    c. discharged home with a sedative.
    d. discharged home to await the onset of true labour.

Answer 28

ANS: D
This situation describes a patient with normal assessments who is probably in prelabour and will probably not give birth rapidly once true labour begins. These are all indications of prelabour without fetal distress. There is no indication that further assessment or Caesarean birth is indicated. The patient will likely be discharged; however, there is no indication that a sedative is needed.

Question 29

29. Which nursing assessment indicates that a patient who is in second-stage labour is almost ready to give birth?
    a. The fetal head is felt at 0 station during vaginal examination.
    b. Bloody mucus discharge increases.
    c. The vulva bulges and encircles the fetal head.
    d. The membranes rupture during a contraction

Answer 29

ANS: C
During the active pushing (descent) phase, the patient has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The vulva stretches and begins to bulge encircling the fetal head. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labour process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labour process and does not indicate an imminent birth.

Question 30

1. Which are possible signs preceding labour? (Select all that apply.)
   a. Weight loss of 2 to 2.5 kg
   b. Surge of energy
   c. Decreased vaginal discharge
   d. Bloody show
   e. Relief from urinary frequency
   f. Backache

Answer 30

ANS: B, D, F
Surge of energy, bloody show and backache are all signs that may precede labour. A weight loss of 0.5 to 1.5 kg may be seen, not 2 to 2.5 kg. Vaginal discharge is increased prior to labour. Urinary frequency returns prior to labour.

Question 31

2. Which factors influence cervical dilation? (Select all that apply.)
   a. Strong uterine contractions
   b. The force of the presenting fetal part against the cervix
   c. The size of the female pelvis
   d. The pressure applied by the amniotic sac
   e. Scarring of the cervix

Answer 31

ANS: A, B, D, E
Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size does not affect cervical dilation.

Question 32

For vaginal birth to be successful, the fetus must adapt to the birth canal during the descent. The turns and other adjustments
necessary in the human birth process are termed the “mechanism of labour.” Please list the seven cardinal movements in the
mechanism of labour in the correct order.
a. Flexion
b. Internal rotation
c. External rotation
d. Expulsion
e. Engagement
f. Descent
g. Extension
1. One
2. Two
3. Three
4. Four
5. Five
6. Six
7. Seven

Answer 32

1. ANS:
2. ANS:
3. ANS: A
4. ANS: B
5. ANS: G
6. ANS: C