Perry - Chapter 13

Question 1

A new mother asks the nurse when the “soft spot” on her son’s head will go away. The nurse’s answer is based on the knowledge that the anterior fontanel closes after birth by _____ months.

a. 2 c. 12
b. 8 d. 18

Answer 1

ANS: D

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

Question 2

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal:

a. Lie. c. Attitude.
b. Presentation. 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 labor at term. Position is the relation of the presenting part to the four quadrants of the mother’s pelvis.

Question 3

When assessing the fetus using Leopold maneuvers, the 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 c. RSA
b. LSP d. LOA

Answer 3

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 positioned in the maternal pelvis.

Question 4

The nurse has received report regarding her patient in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and ?2-2. The nurse’s interpretation of this assessment is that:

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 4

ANS: B
The correct description of the vaginal examination for this woman in labor 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 centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below).

Question 5

To care for a laboring woman adequately, the nurse understands that the __________ stage of labor varies the most in length?

a. First c. Third
b. Second d. Fourth

Answer 5

ANS: A
The first stage of labor 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 labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.

Question 6

The nurse would expect which maternal cardiovascular finding during labor?

a. Increased cardiac output
b. Decreased pulse rate
c. Decreased white blood cell (WBC) count
d. Decreased blood pressure

Answer 6

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 51% above baseline pregnancy values at term. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, 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 7

The factors that affect the process of labor and birth, known commonly as the five Ps, include all except:

a. Passenger. c. Powers.
b. Passageway. d. Pressure.

Answer 7

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

Question 8

The slight overlapping of cranial bones or shaping of the fetal head during labor is called:

a. Lightening. c. Ferguson reflex.
b. Molding. d. Valsalva maneuver.

Answer 8

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

Question 9

Which presentation is described accurately in terms of both presenting part and frequency of occurrence?

a. Cephalic: occiput; at least 95% c. Shoulder: scapula; 10% to 15%
b. Breech: sacrum; 10% to 15% d. Cephalic: cranial; 80% to 85%

Answer 9

ANS: A
In cephalic presentations (head first), the presenting part 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 10

With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that:

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 10

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 11

As relates to fetal positioning during labor, nurses should be aware that:

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 labor.

Answer 11

ANS: B
The station of the presenting part should be noted at the beginning of labor 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. Engagement often occurs in the weeks just before labor in nulliparas and before or during labor in multiparas.

Question 12

Which basic type of pelvis includes the correct description and percentage of occurrence in women?

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 12

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

Question 13

In relation to primary and secondary powers, the maternity nurse comprehends that:

a. Primary powers are responsible for effacement and dilation of the cervix.
b. Effacement generally is well ahead of dilation in women giving birth for the first time; they are closer together in subsequent pregnancies.
c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation.
d. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

Answer 13

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

Question 14

While providing care to a patient in active labor, the nurse should instruct the woman that:

a. The supine position commonly used in the United States increases blood flow.
b. The “all fours” position, on her hands and knees, is hard on her back.
c. Frequent changes in position will help relieve her fatigue and increase her comfort.
d. In a sitting or squatting position, her abdominal muscles will have to work harder.

Answer 14

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 15

Which description of the four stages of labor is correct for both definition and duration?

a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 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 (multiparous women), 50 minutes (first-timer)
d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

Answer 15

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 and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. 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 reestablished (about 2 hours).

Question 16

With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that:

a. The seven critical movements must progress in a more or less orderly sequence.
b. Asynclitism sometimes is achieved by means of the Leopold maneuver.
c. The effects of the forces determining descent are modified by the shape of the woman’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 16

ANS: C
The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the baby’s head; the Leopold maneuver 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 17

In order to evaluate the condition of the patient accurately during labor, the nurse should be aware that:

a. The woman’s blood pressure will increase during contractions and fall back to prelabor normal between contractions.
b. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia.
c. Having the woman point her toes will reduce leg cramps.
d. The endogenous endorphins released during labor will raise the woman’s pain threshold and produce sedation.

Answer 17

ANS: D
The endogenous endorphins released during labor will raise the woman’s pain threshold and produce sedation. In addition, physiologic anesthesia 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 maneuver is discouraged during second stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

Question 18

The maternity nurse understands that as the uterus contracts during labor, 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 18

ANS: C
Uterine contractions during labor 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 19

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 19

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 20

In order to care for obstetric patients adequately, the nurse understands that labor 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 20

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 21

To teach patients about the process of labor adequately, the nurse knows that which event is the best indicator of true labor?

a. Bloody show c. Fetal descent into the pelvic inlet
b. Cervical dilation and effacement d. Uterine contractions every 7 minutes

Answer 21

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

Question 22

Which occurrence is associated with cervical dilation and effacement?

a. Bloody show c. Lightening
b. False labor d. Bladder distention

Answer 22

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 false labor. Lightening is the descent of the fetus toward the pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied frequently. It may slow down the descent of the fetus during labor.

Question 23

The primary difference between the labor of a nullipara and that of a multipara is the:

a. Amount of cervical dilation. c. Level of pain experienced.
b. Total duration of labor. d. Sequence of labor mechanisms.

Answer 23

ANS: B
In a first-time pregnancy, descent is usually slow but steady; in subsequent pregnancies, descent is more rapid, resulting in a shorter duration of labor. Cervical dilation is the same for all labors. Level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms is the same with all labors.

Question 24

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 woman to be:

a. Admitted and prepared for a cesarean birth.
b. Admitted for extended observation.
c. Discharged home with a sedative.
d. Discharged home to await the onset of true labor.

Answer 24

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

Question 25

Which nursing assessment indicates that a woman who is in second-stage labor 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 25

ANS: C
During the active pushing (descent) phase, the woman 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 labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.

Question 26

Signs that precede labor include (Select all that apply):

a. Lightening.
b. Exhaustion.
c. Bloody show.
d. Rupture of membranes.
e. Decreased fetal movement.

Answer 26

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

Question 27

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 27

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

Question 28

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 labor.” Please list the seven cardinal movements in the mechanism of labor in the correct order.

a. Flexion e. Engagement
b. Internal rotation f. Descent
c. External rotation g. Extension
d. Expulsion

28. One
29. Two
30. Three
31. Four
32. Five
33. Six
34. Seven

Answer 28

28. ANS: E
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).
29. ANS: F
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).
30. ANS: A
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).
31. ANS: B
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).
32. ANS: G
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).
33. ANS: C
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).
34. ANS: D
    In a vertex presentation the cardinal movements, in order, are: engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and finally birth by expulsion. Although these movements are discussed separately, in actuality a combination of movements occurs simultaneously (i.e., engagement involves both descent and flexion).