Chapter 19: Nursing Care of the Family During Labor and Birth

Question 1

the first stage of labor is often called the stage of ________

Answer 1

dilation

Question 2

the first stage of labor begins with ______ and ends with _______

Answer 2

onset of regular uterine contractions; complete dilation of the cervix

Question 3

what stage of labor is most often the longest?

Answer 3

the first stage

Question 4

three distinct phases of the first stage of labor

Answer 4

1. latent
2. active
3. transition

Question 5

the ______ phase of labor begins with the establishment of regular contractions

Answer 5

latent

Question 6

during the latent phase contractions are usually about ______ minutes apart and last ______ seconds

Answer 6

5 minutes apart; 30-45 seconds

Question 7

during the latent phase the cervix dilates_______

Answer 7

0-3 cm

Question 8

the latent phase can last up to _______

Answer 8

10-14 hours

Question 9

contractions in the active phase occur every _______ minutes and last _______ seconds

Answer 9

3-5 minutes; 45- 60 seconds

Question 10

active phase of labor the cervix dilates to ________

Answer 10

4-7 cm

Question 11

_______is the most intense phase of labor

Answer 11

transition

Question 12

transition is characterized by frequent, strong contractions that occur every _______ minutes and last ________ seconds

Answer 12

2-3 minutes; 60-90 seconds

Question 13

stage 1 usually lasts ________ hours for primipara and ______ hours for multiparas

Answer 13

10; 8

Question 14

the second stage of labor begins with _______ and ends with __________

Answer 14

full dilation of the cervix; birth of the infant

Question 15

the nurse may suspect the second stage of labor has begun when:

Answer 15

the mother feels an urge to push or involuntarily bear down

Question 16

What is crowning

Answer 16

just before external rotation and the fetal and expulsion, the fetal head is in OA position

Question 17

these things increase during labor: 
1.
2.
3.
4.
5.

Answer 17

1. WBC
2. CO
3. HR/RR
4. temp
5. BP during contractions (goes back to baseline during relaxation)

Question 18

new phases of stage 1 of labor: (only 2)

Answer 18

1. Latent

2. Active (6-10 cm)

Question 19

these things decrease during labor:
1.
2.

Answer 19

1. Maternal blood glucose

2. GI motility

Question 20

______ provides predictive and reliable information about fetal oxygenation

Answer 20

Fetal heart rate

Question 21

fetal heart sounds are best heard over ________ when the fetus is in ______ position

Answer 21

the fetal back; flexed position

Question 22

typically with a cephalic presentation, the fetal heart sounds are best auscultated_____________

Answer 22

below the level of the maternal umbilicus

Question 23

in a ROA presentation, the fetal heart sounds are best heard when auscultated ________

Answer 23

right lower quadrant

Question 24

in a breech presentation the fetal heart sounds are best heard when auscultated ___________

Answer 24

above the level of the umbilicus

Question 25

in LSA position, the fetal heart sounds are best heard when auscultated _________

Answer 25

upper left quadrant

Question 26

________ decreases fetal circulation

Answer 26

uterine contractions

Question 27

during a low risk pregnancy, how often are maternal vital signs taken?

Answer 27

- V/S every hour - temp every 4 hours while membranes are in tact - temp every two hours after ROM

Question 28

during a high risk pregnancy, how often are maternal vital signs taken?

Answer 28

- monitor every 15-30 minutes | - temp every 2-4 hours based on membrane status

Question 29

during the active phase of labor how much effacement occurs?

Answer 29

40-80% (usually 100 % in primiparas)

Question 30

after an epidural or Foley insertion the mother's vital signs should be monitored __________

Answer 30

every 1-2 minutes

Question 31

___________ reveals whether a woman is in true labor and if the membranes have ruptures

Answer 31

vaginal examination

Question 32

what laboratory tests and assessments are done when the pt arrives in suspected labor? (six major tests)

Answer 32

1. CBC 2. Urinalysis 3. HIV 4. Type and screen 5. GBS if status is unknown 6. assessment of amniotic fluids

Question 33

Mechanism of Labor in order (7 steps)

Answer 33

1. engagement 2. descent 3. flexion 4. internal rotation 5. extension 6. external rotation 7. expulsion

Question 34

______ describes the fetal head passing through the pelvic inlet

Answer 34

engagement

Question 35

__________ refers to the fetus moving into the birth canal

Answer 35

descent

Question 36

_______ refers to the fetus moving its chin toward its chest

Answer 36

flexion

Question 37

________ refers to the fetal head aligning with the long axis of the maternal pelvis

Answer 37

internal rotation

Question 38

________ refers to the fetus head position when the head is delivered

Answer 38

extension

Question 39

_______ describes when the fetal shoulders align along the anteroposterior diameter

Answer 39

external rotation

Question 40

________ refers to when the fetal shoulders and body are delivered

Answer 40

expulsion

Question 41

first degree perineal tear

Answer 41

injury to the perineal skin and vaginal epithelium only

Question 42

second degree perineal tear

Answer 42

extends to fascia and muscles of perineal area

Question 43

third degree perineal tear

Answer 43

injury through fascia and muscles of perineal area and also extends to the anal sphincter complex

Question 44

fourth degree perineal tear

Answer 44

perineal fascia & muscles, anal sphincter, and anal epithelium

Question 45

_______ is when the woman begins pushing at full cervical dilation regardless of the urge to bear down

Answer 45

closed-glottis pushing (aka directed pushing)

Question 46

________ is the recommended method of pushing and occurs only when the mother feels the urge to bear down

Answer 46

open glottis pushing (aka involuntary pushing)

Question 47

as the fetal head progresses downward the the perineum begins to stretch, thin out, and move ________

Answer 47

anteriorly

Question 48

cord clamping should be delayed _______

Answer 48

60 -120 seconds, or when cord stops pulsating

Question 49

third stage of labor begins with ______ and ends with ______

Answer 49

birth of the infant; delivery of the placenta

Question 50

during the third stage of labor it is common to see_____ and _____

Answer 50

cord lengthen; trickle of blood from the vagina

Question 51

``` the following indicate separation of the placenta from the uterus: 1. 2. 3. 4. ```

Answer 51

1. uterus becomes spherical in shape 2. uterus rises upward in the abdomen 3. umbilical cord descends further through the vagina 4. a gush of blood occurs once the placenta detaches from the uterus

Question 52

if a peripheral IV infusion is established then ______ units of Pitocin is administered after the delivery of the placenta

Answer 52

10-20 units

Question 53

if no peripheral IV infusion is established then ______ units of Pitocin is given _______ after the delivery of the placenta

Answer 53

10; intramuscularly

Question 54

after the delivery of the placenta vital signs of mother should be closely monitored, focusing on ______ and _____

Answer 54

BP; HR

Question 55

the fourth stage of labor begins with _____ and ends with ________

Answer 55

after the delivery of the placenta; within 1-2 hours after delivery

Question 56

``` key characteristics of the fourth stage of labor include: 1. 2. 3. 4. ```

Answer 56

1. Newborn is assessed 2. medications are given- mother and baby 3. mother may breastfeed for the first time 4. maternal/infant bonding is encouraged (skin to skin)

Question 57

_______ is used to assess the transition stage from fetus to neonate

Answer 57

Apgar scoring

Question 58

The Apgar Scoring system evaluates five signs of newborn cardiopulmonary adaptation and neuromuscular function:

Answer 58

1. heart rate 2. respiratory effort 3. muscle tone 4. reflex irritability 5. color

Question 59

slow heart rate in a newborn would be ________

Answer 59

below 100 BPM

Question 60

sign of adequate respiratory effort in neonate

Answer 60

vigorous cry

Question 61

sign of good muscle tone in a neonate

Answer 61

the babies extremities return to a flexed position after the nurse extends them

Question 62

how is reflex irritability tested in neonates

Answer 62

after gently stroking the spine or flicking the foot the baby should cry (2 points) or at least grimace (1 point)

Question 63

acrocyanosis

Answer 63

most newborns exhibit cyanosis in the extremities during the 1 minute APGAR score and it is known as acrocyanosis

Question 64

during the fourth stage of labor the nurse assesses the mother's uterus for _______, ________, and _______

Answer 64

firmness; height; position

Question 65

where should the fundus be palpable following birth of the fetus and placenta

Answer 65

midline at or just below the umbilicus

Question 66

a soft, or "boggy" uterus on palpation indicates:

Answer 66

excessive blood and/or blood clots have pooled in the uterus

Question 67

what should the nurse do if the uterus feels boggy

Answer 67

massage the fundus until it feels firm

Question 68

________ soaked pad(s) within the first postpartum hour is considered the normal maximum flow

Answer 68

1

Question 69

a rising pulse and lower blood pressure of the mother following delivery is a sign of

Answer 69

hemorrhaging

Question 70

_______ must be well contracted following delivery of baby and placenta

Answer 70

myometrium

Question 71

``` a woman who had a C-section will go to the PAR (post-anesthesia recovery) unit where they will assess: 1. 2. 3. 4. 5. ```

Answer 71

1. activity 2. respirations 3. BP 4. level of consciousness 5. color