Exam 2 - Chapter 19 Flashcards
The nurse recognizes that a woman is in true labor when she states:
a.
“I passed some thick, pink mucus when I urinated this morning.”
b.
“My bag of waters just broke.”
c.
“The contractions in my uterus are getting stronger and closer together.”
d.
“My baby dropped, and I have to urinate more frequently now.”
C - Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.
Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor.
Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor.
The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.
When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:
a.
Tell the woman to stay home until her membranes rupture
b.
Emphasize that food and fluid intake should stop
c.
Arrange for the woman to come to the hospital for labor evaluation
d.
Ask the woman to describe why she believes she is in labor
D - Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data.
The initial nursing activity should be to gather data about the woman’s status. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular.
The initial nursing activity should be to gather data about the woman’s status. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.
Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for \_\_\_\_\_ has increased. a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension
A - When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis.
Rupture of membranes (ROM) is not associated with fetal or maternal bleeding.
Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor.
ROM has no correlation with supine hypotension.
The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg, and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. Based on this information, the nurse should:
a.
Notify the woman’s primary health care provider immediately
b.
Prepare to administer an oxytocic to stimulate uterine activity
c.
Document the findings because they reflect the expected contraction pattern for the active phase of labor
d.
Prepare the woman for the onset of the second stage of labor
C - The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. Additionally the nurse documents these findings in the client’s medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor.
Nothing indicates a need to notify the primary health care provider at this time.
Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor.
Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions?
a.
Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips.
b.
Determine the frequency by timing from the end of one contraction to the end of the next contraction.
c.
Evaluate the intensity by pressing the fingertips into the uterine fundus.
d.
Assess uterine contractions every 30 minutes throughout the first stage of labor.
C - 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.
The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction.
Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective is: a. Dilation of the cervix b. Descent of the fetus c. Rupture of the amniotic membranes d. Increase in bloody show
A - 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.
Descent of the fetus, or engagement, may occur before labor.
Rupture of membranes may occur with or without the presence of labor.
Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.
The nurse who performs vaginal examinations to assess a woman’s progress in labor should:
a.
Perform an examination at least once every hour during the active phase of labor
b.
Perform the examination with the woman in the supine position
c.
Wear two clean gloves for each examination
d.
Discuss the findings with the woman and her partner
D - The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider.
A vaginal examination should be performed only when indicated by the status of the woman and her fetus.
The woman should be positioned so as to avoid supine hypotension.
The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse’s initial response is to:
a.
Prepare the woman for imminent birth
b.
Notify the woman’s primary health care provider
c.
Document the characteristics of the fluid
d.
Assess the fetal heart rate and pattern
D - The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented.
Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent.
The nurse may notify the primary health care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse’s priority is to assess fetal well-being.
The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.
The nurse should assist the laboring woman into a hands-and-knees position when:
a.
The occiput of the fetus is in a posterior position
b.
The fetus is at or above the ischial spines
c.
The fetus is in a vertex presentation
d.
The membranes rupture
A - The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position.
Many women experience the irresistible urge to push when the fetus is at the level of the ischial spines. In some cases this occurs before the woman is fully dilated. The woman should be instructed not to push until complete cervical dilation has occurred.
No one position is correct for childbirth. The two most common positions assumed by women are the sitting and side-lying positions.
The woman may be encouraged into a hands-and-knees position if the umbilical cord prolapsed when the membranes ruptured.
A nulliparous woman who has just begun the second stage of her labor most likely:
a.
Experiences a strong urge to bear down
b.
Shows perineal bulging
c.
Feels tired yet relieved that the worst is over
d.
Shows an increase in bright red bloody show
C - Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because “the worst is over.” The woman may be very quiet during this phase.
During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions.
Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage.
An increase in bright red bloody show occurs during the descent phase of the second stage of labor.
The nurse knows that the second stage of labor, the descent phase, has begun when:
a.
The amniotic membranes rupture
b.
The cervix cannot be felt during a vaginal examination
c.
The woman experiences a strong urge to bear down
d.
The presenting part is below the ischial spines
C - During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down.
Rupture of membranes (ROM) has no significance in determining the stage of labor.
The second stage of labor begins with full cervical dilation.
Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm dilation.
Through vaginal examination, the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3½ to 4 minutes. The nurse reports this as: a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage, latent phase
B - This maternal progress indicates that the woman is in the active phase of the first stage of labor.
During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes.
During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes.
During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of “laboring down.”
The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the airway clear b. Fostering parent-newborn attachment c. Drying the newborn and wrapping the infant in a blanket d. Administering eye drops and vitamin K
A - The care given immediately after the birth focuses on assessing and stabilizing the newborn.
Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth.
The care given immediately after birth focuses on assessing and stabilizing the newborn. The nursing activities are (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering 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 partner or the mother the infant.
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. Relieve pain b. Stimulate uterine contraction c. Prevent infection d. Facilitate rest and relaxation
B - Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor.
Oxytocics are not used to treat pain.
Oxytocics do not prevent infection.
Oxytocics do not facilitate rest and relaxation.
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?
a.
Latent: mild, regular contractions; no dilation; bloody show
b.
Active: moderate, regular contractions; 4 to 7 cm dilation
c.
Lull: no contractions; dilation stable
d.
Transition: very strong but irregular contractions; 8 to 10 cm dilation
B - The active phase is characterized by moderate, regular contractions, 4 to 7 cm dilation, and a duration of 3 to 6 hours.
The latent phase is characterized by mild to moderate, irregular contractions, dilation up to 3 cm, brownish to pale pink mucus, and a duration of 6 to 8 hours.
No official “lull” phase exists in the first stage.
The transition phase is characterized by strong to very strong, regular contractions, 8 to 10 cm dilation, and a duration of 20 to 40 minutes.