Quiz 3 Flashcards
A woman pregnant for the first time.
primigravida
A woman pregnant for at least the third time.
Multigravida
A woman who has had two or more pregnancies of at least 20 weeks’ gestation resulting in viable offspring.
multipara
A woman who has not produced a viable offspring.
nullipara
The failure of the uterus to contract and retract after birth.
uterine atony
A medication used to induce contraction or greater muscle strength of the uterus.
uterotonic medication
Medications that are used to slow or stop contractions of the uterus.
tocolytics
T/F
Loss of mucous plug is normal and does not mean labor is imminent.
true
A laboring patient has entered the second stage of labor. Which assessment finding is most consistent with this stage?
A. Cervical dilation at 4 cm with mild contractions
B. Contractions occurring every 2–3 minutes, lasting 60–90 seconds
C. Expulsion of the placenta
D. Close monitoring of maternal vital signs and newborn stability
B. Contractions occurring every 2–3 minutes, lasting 60–90 seconds
Rationale: The second stage of labor begins when the cervix is completely dilated and ends with the birth of the newborn. Contractions during this stage are typically strong, occurring every 2–3 minutes, and lasting 60–90 seconds.
Which intervention is most critical during the third stage of labor?
A. Encouraging the patient to push with each contraction
B. Providing ice packs to the perineal area for swelling
C. Monitoring for uterine atony and excessive bleeding
D. Assessing maternal vital signs every 15 minutes
C. Monitoring for uterine atony and excessive bleeding
Rationale: The third stage of labor involves the expulsion of the placenta. Monitoring for uterine atony and excessive bleeding is critical during this stage to prevent postpartum hemorrhage.
The nurse is caring for a postpartum patient in the fourth stage of labor. Which finding would require immediate intervention?
A. Uterine fundus firm and midline
B. Heavy vaginal bleeding with clots
C. Maternal vital signs stable
D. Newborn in skin-to-skin contact with the mother
B. Heavy vaginal bleeding with clots
Rationale: The fourth stage of labor is the restorative period when the mother’s body begins to stabilize. Heavy vaginal bleeding with clots is abnormal and may indicate postpartum hemorrhage, requiring immediate intervention.
A patient in active labor asks how long the first stage of labor will last. Which response by the nurse is most appropriate?
A. “The first stage typically lasts 5–6 hours for all women.”
B. “It ends when you begin pushing, and that should happen in about 2 hours.”
C. “This stage is the shortest, lasting 1–2 hours.”
D. “It depends on how quickly your cervix dilates, but it is generally the longest stage of labor.”
D. “It depends on how quickly your cervix dilates, but it is generally the longest stage of labor.”
Rationale: The first stage of labor is the longest and varies in duration, depending on factors such as whether the patient is a first-time mother (nulliparous) or has delivered before (multiparous). It begins with true contractions and ends with full cervical dilation.
During the first stage of labor, which primary factor contributes to the pain experienced by the laboring patient?
A. Distention of the cervix and lower uterine segment
B. Compression of the fetal head against the pelvis
C. Expulsion of the placenta
D. Pressure on the perineum during contractions
A. Distention of the cervix and lower uterine segment
Rationale: Pain during the first stage of labor primarily results from cervical and lower uterine segment dilation, as well as the stretching of these structures during uterine contractions.
A nurse is caring for a multiparous patient in the first stage of labor. Based on the average duration for this stage, what should the nurse anticipate?
A. The first stage will last no longer than 8 hours
B. The first stage may last up to 20 hours
C. The first stage may last up to 14 hours
D. The first stage will not exceed 10 hours
C. The first stage may last up to 14 hours
Rationale: For multiparous women, the first stage of labor can last up to 14 hours without being considered prolonged. For primigravidas, it may last up to 20 hours.
Which assessment finding indicates the end of the first stage of labor?
A. Cervical dilation at 10 cm
B. Complete effacement of the cervix
C. Fetal membranes have ruptured
D. Regular contractions lasting 60 seconds
A. Cervical dilation at 10 cm
Rationale: The first stage of labor ends when the cervix is fully dilated to 10 cm, allowing the fetal head to pass through.
A primigravida patient asks why her labor is taking longer than expected. What is the best response by the nurse?
A. “Labor always takes longer for first-time mothers.”
B. “You may need an intervention if your labor doesn’t progress soon.”
C. “The first stage can take up to 20 hours for first-time mothers, but this is normal.”
D. “The duration depends on the size of your baby’s head.”
C. “The first stage can take up to 20 hours for first-time mothers, but this is normal.”
Rationale: For first-time mothers (primigravidas), the first stage of labor can last up to 20 hours without being considered prolonged. This is due to the time it takes for the cervix to dilate fully.
During a vaginal examination, the nurse determines that a laboring patient’s cervix is dilated to 7 cm. Which phase of the first stage of labor is the patient experiencing?
A. Transition phase
B. Latent phase
C. Active phase
D. Expulsive phase
C. Active phase
Rationale: The active phase of the first stage of labor is characterized by cervical dilation from 4 to 10 cm. This phase involves more rapid cervical dilation compared to the latent phase.
Which cervical dilation measurement is most consistent with the latent phase of labor?
A. 1–6 cm
B. 6–10 cm
C. 7–8 cm
D. 0–2 cm
A. 1–6 cm
Rationale: The latent phase of labor begins with the onset of regular contractions and ends when rapid cervical dilation begins. Cervical dilation progresses slowly during this phase, reaching approximately 6 cm.
A nurse is assessing a laboring patient during the latent phase. Which contraction characteristics are expected during this phase?
A. Occur every 2–3 minutes, lasting 60–90 seconds, and are strong by palpation
B. Occur every 5–10 minutes, lasting 30–45 seconds, and are mild by palpation
C. Occur every 5–10 minutes, lasting 60–90 seconds, and are moderate by palpation
D. Occur every 2–3 minutes, lasting 30–45 seconds, and are strong by palpation
B. Occur every 5–10 minutes, lasting 30–45 seconds, and are mild by palpation
Rationale: In the latent phase, contractions are mild, occur every 5–10 minutes, and last 30–45 seconds. The intensity is mild enough that the uterine fundus can be indented during palpation at the peak of the contraction.
During the latent phase of labor, which behavior is most commonly observed in the laboring woman?
A. Focused and intent on pushing
B. Restless and unable to communicate
C. Talkative and perceiving contractions as menstrual cramps
D. Silent and breathing deeply through contractions
C. Talkative and perceiving contractions as menstrual cramps
Rationale: Women in the latent phase are often talkative and may describe contractions as similar to menstrual cramps. This phase is characterized by excitement and apprehension about the start of labor.
What factor could prolong the latent phase of labor?
A. Administering sedation to the laboring woman
B. Use of oxytocin for labor augmentation
C. Early rupture of membranes
D. Strong uterine contractions
A. Administering sedation to the laboring woman
Rationale: Sedation can prolong the latent phase of labor by slowing the progression of cervical dilation.
A nurse palpates the fundus during a contraction and notes that it can be easily indented with her fingers. How should the nurse document the contraction intensity?
A. Strong
B. Moderate
C. Mild
D. Absent
C. Mild
Rationale: During the latent phase of labor, mild contractions are common. These can be assessed by palpating the uterine fundus; if it can be easily indented at the peak of the contraction, the intensity is considered mild.
Which assessment finding is most consistent with a laboring woman in the active phase of labor?
A. Contractions occurring every 5–10 minutes, lasting 30–45 seconds, and mild by palpation
B. Cervical dilation of 4–6 cm with mild discomfort
C. Contractions every 2–5 minutes, lasting 45–60 seconds, and moderate to strong by palpation
D. Cervical dilation of 10 cm with an urge to push
C. Contractions every 2–5 minutes, lasting 45–60 seconds, and moderate to strong by palpation
Rationale: During the active phase, contractions increase in frequency (every 2–5 minutes), duration (45–60 seconds), and intensity (moderate to strong). Cervical dilation occurs more rapidly compared to the latent phase.
What is the expected rate of cervical dilation during the active phase of labor?
A. 0.5 cm per hour
B. 1.0 cm per hour
C. 1.2 to 1.5 cm per hour
D. 2.0 to 2.5 cm per hour
C. 1.2 to 1.5 cm per hour
Rationale: Cervical dilation during the active phase of labor progresses predictably at a rate of approximately 1.2 to 1.5 cm per hour.
A laboring patient in the active phase begins to limit interactions with those in the room and appears focused on her contractions. What is the most appropriate nursing intervention?
A. Encourage her to engage with visitors to distract from the pain
B. Offer support by guiding her through relaxation and breathing techniques
C. Increase her activity level to promote faster cervical dilation
D. Administer sedatives to help her rest during labor
B. Offer support by guiding her through relaxation and breathing techniques
Rationale: During the active phase, women often become more inwardly focused to cope with the intensity of contractions. Supporting her with relaxation and breathing techniques helps her manage discomfort effectively.
Which physiological change is a hallmark of the active phase of labor?
A. Rapid and predictable cervical dilation
B. Complete effacement of the cervix
C. Rupture of the membranes
D. Transition of the fetus into the birth canal
A. Rapid and predictable cervical dilation
Rationale: The active phase of labor is characterized by a significant increase in the rate of cervical dilation, progressing rapidly and predictably until complete dilation at 10 cm.
A patient in active labor reports intense discomfort during contractions. The nurse palpates the uterine fundus and finds it difficult to indent at the peak of a contraction. How should the nurse document the contraction intensity?
A. Mild
B. Moderate
C. Strong
D. Absent
C. Strong
Rationale: Contractions during the active phase are typically moderate to strong in intensity. A fundus that is difficult to indent indicates strong contractions.
Which behavioral change is commonly observed in a woman during the active phase of labor?
A. Use of relaxation and paced breathing techniques
B. Increased interaction with her support team
C. Excitement and talkativeness
D. Urge to push with each contraction
A. Use of relaxation and paced breathing techniques
Rationale: Women in the active phase of labor often focus on coping with the increasing discomfort of contractions. If they have attended childbirth education classes, they typically employ relaxation and paced breathing techniques to manage their labor.
What physiological change signals the beginning of the second stage of labor?
A. Complete effacement of the cervix
B. Complete cervical dilation to 10 cm
C. Rupture of membranes
D. Fetal engagement in the pelvis
B. Complete cervical dilation to 10 cm
Rationale: The second stage of labor begins when the cervix is fully dilated to 10 cm and effacement is complete, marking the transition from cervical preparation to fetal descent through the birth canal.
A laboring patient in the second stage experiences an overwhelming urge to push. What causes this sensation?
A. Release of oxytocin during contractions
B. Pressure from the fetus on the pelvic floor and stretch receptors in the vaginal walls
C. Increased strength and duration of uterine contractions
D. Hormonal changes due to the expulsion of the placenta
B. Pressure from the fetus on the pelvic floor and stretch receptors in the vaginal walls
Rationale: The urge to push is caused by the fetus applying direct pressure to the pelvic floor, stimulating stretch receptors in the vaginal walls, rectum, and perineum, and leading to increased abdominal pressure.
Which contraction characteristics are expected during the second stage of labor?
A. Every 5–10 minutes, lasting 30–45 seconds, and mild by palpation
B. Every 2–3 minutes, lasting 60–90 seconds, and strong by palpation
C. Every 2–3 minutes, lasting 30–45 seconds, and moderate by palpation
D. Every 5–10 minutes, lasting 60–90 seconds, and strong by palpation
B. Every 2–3 minutes, lasting 60–90 seconds, and strong by palpation
Rationale: During the second stage, contractions occur every 2–3 minutes, last 60–90 seconds, and are strong by palpation to aid in the expulsion of the fetus through the birth canal.
Which maternal factors can prolong the second stage of labor?
A. Parity and presence of Braxton Hicks contractions
B. Maternal age and previous cesarean delivery
C. Uterine rupture and active hemorrhage
D. Maternal BMI, fetal station, and use of epidural analgesia
D. Maternal BMI, fetal station, and use of epidural analgesia
Rationale: Factors such as maternal BMI, delayed pushing, use of epidural analgesia, fetal station at complete dilation, and fetal positioning (e.g., occiput posterior) can prolong the second stage of labor.
Which complication is associated with a prolonged second stage of labor?
A. Umbilical cord prolapse
B. Preeclampsia
C. Third- and fourth-degree perineal lacerations
D. Amniotic fluid embolism
C. Third- and fourth-degree perineal lacerations
Rationale: Prolonged second stage of labor increases the risk of maternal complications such as perineal lacerations, puerperal infections, and postpartum hemorrhage.
During the second stage of labor, a patient expresses feelings of control and focus while pushing. What is the most appropriate nursing action?
A. Encourage the patient to continue pushing during contractions
B. Prepare the patient for an emergency cesarean section
C. Administer a sedative to help the patient rest
D. Interrupt pushing to assess for uterine rupture
A. Encourage the patient to continue pushing during contractions
Rationale: During the second stage, the mother often feels in control and focused on pushing. The nurse should provide encouragement and guidance to support effective pushing efforts during contractions.
What is the primary function of the cardinal movements of labor during the second stage?
A. Reduce maternal pain during contractions
B. Encourage uterine relaxation between contractions
C. Prevent fetal distress during labor
D. Facilitate the fetus’s movement through the birth canal
D. Facilitate the fetus’s movement through the birth canal
Rationale: The cardinal movements of labor are a series of positional changes that the fetus undergoes to navigate the birth canal and facilitate delivery.
A nurse is assessing a laboring patient in the second stage. Which finding indicates that the fetus is descending through the birth canal?
A. Fetal heart rate variability
B. Rupture of membranes
C. Contractions spaced further apart
D. Pressure felt in the pelvic floor and rectum
D. Pressure felt in the pelvic floor and rectum
Rationale: Pressure in the pelvic floor and rectum indicates fetal descent through the birth canal, stimulating stretch receptors and contributing to the maternal urge to push.
What physiological change is associated with the crowning of the fetal head during labor?
A. The fetal head becomes apparent at the vaginal opening and disappears between contractions.
B. The top of the fetal head remains visible between contractions.
C. The fetal head rotates internally during contractions.
D. The fetal presenting part exerts pressure on the rectum.
B. The top of the fetal head remains visible between contractions.
Rationale: Crowning occurs when the top of the fetal head no longer regresses between contractions and remains visible at the vaginal opening.
Which assessment finding is most consistent with the active pushing phase of labor?
A. Mild contractions occurring every 5–10 minutes
B. Full cervical dilation with a lack of bloody show
C. Rectal pressure and an overwhelming urge to push
D. Complete delivery of the placenta
C. Rectal pressure and an overwhelming urge to push
Rationale: During active pushing, the laboring mother feels rectal pressure caused by the fetal presenting part and experiences a physiological urge to push.
How does an epidural affect the active pushing phase of labor?
A. It dulls the sensation to push.
B. It intensifies the urge to push.
C. It shortens the duration of labor.
D. It eliminates bloody show.
A. It dulls the sensation to push.
Rationale: An epidural can dull the physiological urge to push, making the pushing phase less intense for the laboring mother.
What is a normal duration for the second stage of labor in a multiparous woman?
A. Up to 1 hour
B. Up to 2 hours
C. Up to 3 hours
D. Up to 4 hours
B. Up to 2 hours
Rationale: In multiparous women, the second stage of labor typically lasts up to 2 hours. In first labors, it may last up to 3 hours.
Which finding is a key indicator of progression during the second stage of labor?
A. Perineum bulging and increased bloody show
B. Uterine relaxation between contractions
C. Absence of fetal head at the vaginal opening
D. Contractions occurring every 5–10 minutes
A. Perineum bulging and increased bloody show
Rationale: The bulging of the perineum and an increase in bloody show indicate that the fetus is descending and labor is progressing during the second stage.
A nurse observes that the fetal head becomes visible at the vaginal opening but disappears between contractions. How should this stage of labor be documented?
A. Crowning
B. Early second stage
C. Late second stage
D. Fetal head engagement
C. Late second stage
Rationale: In the late second stage of labor, the fetal head becomes visible but may still regress between contractions until crowning occurs.
Which statement reflects current evidence about labor progression during the second stage?
A. The second stage progresses more rapidly than previously thought.
B. Labor progresses slower than previously thought, requiring more time for vaginal delivery.
C. Women with epidurals progress faster than those without epidurals.
D. Crowning is an indicator to initiate surgical birth.
B. Labor progresses slower than previously thought, requiring more time for vaginal delivery.
Rationale: Current evidence shows that labor progresses more slowly than previously believed, and many women may need additional time to achieve vaginal delivery without moving to surgical interventions.
What is the primary advantage of spontaneous pushing during the second stage of labor?
A. It reduces the total duration of the second stage.
B. It eliminates the need for maternal energy expenditure.
C. It prevents fetal descent.
D. It minimizes the risk of pelvic floor damage.
D. It minimizes the risk of pelvic floor damage.
Rationale: Spontaneous pushing reduces pelvic floor damage by avoiding the prolonged Valsalva maneuver, which is associated with more strain and injury.
Which is a significant drawback of directed pushing during labor?
A. Decreases maternal pain perception
B. Prolongs the overall labor process
C. Reduces fetal oxygenation and causes hemodynamic changes
D. Eliminates maternal participation
C. Reduces fetal oxygenation and causes hemodynamic changes
Rationale: Directed pushing, especially prolonged Valsalva bearing-down, can lead to hemodynamic changes in the mother and interfere with fetal oxygen exchange.
What is the World Health Organization’s (WHO) recommendation for managing the second stage of labor?
A. Encouraging women to follow their spontaneous urge to push
B. Immediate and directed pushing efforts after complete cervical dilation
C. Continuous monitoring and direction by the healthcare provider
D. Delaying pushing until the fetus crowns
A. Encouraging women to follow their spontaneous urge to push
Rationale: The WHO recommends encouraging women to follow their own urge to push rather than using directed pushing.
Which maternal behavior is consistent with a physiologic, woman-directed approach to pushing?
A. Using open-glottis pushing with grunting and vocalization
B. Holding their breath to the count of 10 during contractions
C. Pushing at fixed intervals based on caregiver instructions
D. Maintaining one position throughout labor
A. Using open-glottis pushing with grunting and vocalization
Rationale: A physiologic, woman-directed approach involves open-glottis pushing, allowing the mother to bear down naturally with involuntary efforts.
What is a primary benefit of delaying maternal pushing until the urge to bear down is felt?
A. Shortens the total time of labor
B. Increases the rate of cervical dilation
C. Prevents the need for epidural analgesia
D. Reduces maternal fatigue and improves fetal oxygenation
D. Reduces maternal fatigue and improves fetal oxygenation
Rationale: Delaying pushing conserves maternal energy and allows for better oxygenation of the fetus, optimizing outcomes for both mother and baby.
Which technique is associated with a physiologic approach to laboring down?
A. Coached Valsalva pushing immediately after complete cervical dilation
B. Passive fetal descent without maternal pushing
C. Using sustained breath-holding during contractions
D. Applying external fundal pressure to speed delivery
B. Passive fetal descent without maternal pushing
Rationale: Laboring down involves allowing passive fetal descent with minimal or no maternal pushing, particularly in women with epidurals.
Which of the following is a potential negative consequence of prolonged directed pushing?
A. Decreased maternal pain perception
B. Improved fetal oxygen exchange
C. Increased pelvic floor damage
D. Shortened second stage of labor
C. Increased pelvic floor damage
Rationale: Prolonged directed pushing increases the risk of pelvic floor damage and adverse maternal outcomes.
Which method best supports maternal energy conservation and optimal second-stage outcomes?
A. Encouraging laboring down
B. Immediate directed pushing after complete dilation
C. Using continuous maternal breath-holding
D. Limiting maternal positions to supine
A. Encouraging laboring down
Rationale: Laboring down allows for passive fetal descent, conserving maternal energy and improving overall outcomes.
Which technique is an example of evidence-based second-stage labor management?
A. Instructing the mother to push for 10 seconds with each contraction
B. Encouraging the mother to use her own pushing techniques
C. Administering fundal pressure to assist fetal descent
D. Restricting movement to one position during labor
B. Encouraging the mother to use her own pushing techniques
Rationale: Evidence-based management supports the mother’s spontaneous patterns and techniques of pushing in response to her sensations.
What physiological change occurs during open-glottis pushing?
A. Increased intrathoracic pressure from breath-holding
B. Decreased strength and duration of contractions
C. Expiratory grunting with involuntary bearing down
D. Improved maternal blood pressure regulation
C. Expiratory grunting with involuntary bearing down
Rationale: Open-glottis pushing involves natural expiratory grunting and involuntary bearing down, which aligns with the body’s physiological processes.
Which factor contributes to the decision to delay maternal pushing?
A. A belief that delayed pushing increases cesarean rates
B. The need for constant caregiver monitoring
C. Reduced uterine contractions during the delay
D. Evidence suggesting improved maternal energy and fetal oxygenation
D. Evidence suggesting improved maternal energy and fetal oxygenation
Rationale: Delaying pushing optimizes maternal energy and enhances fetal oxygenation without increasing adverse outcomes.
Which maternal behavior indicates effective second-stage labor management?
A. Pushing at caregiver-directed intervals
B. Spontaneous variations in strength and duration of pushing
C. Avoiding vocalization during contractions
D. Maintaining a supine position throughout labor
B. Spontaneous variations in strength and duration of pushing
Rationale: Effective second-stage management involves the mother using her own natural patterns, including variations in strength and duration of pushing.
What should the nurse prioritize in evidence-based care during the second stage of labor?
A. Directing the mother to hold her breath during contractions
B. Supporting the mother’s spontaneous urge and position changes
C. Encouraging immediate epidural administration
D. Applying manual fundal pressure to speed labor
B. Supporting the mother’s spontaneous urge and position changes
Rationale: Evidence-based care during the second stage prioritizes supporting the mother’s natural instincts and encouraging position changes to enhance comfort and labor progress.
Which nursing intervention is the highest priority during the third stage of labor?
A. Monitoring maternal vital signs every 15 minutes
B. Assessing for signs of placental separation
C. Promoting immediate skin-to-skin contact between the newborn and mother
D. Administering a uterotonic agent as ordered
D. Administering a uterotonic agent as ordered
Rationale: Administering a uterotonic agent is critical to preventing postpartum hemorrhage, the leading cause of maternal mortality during the third stage of labor.
What indicates that placental separation has occurred?
A. A sudden gush of blood and lengthening of the umbilical cord
B. The uterus becomes soft and non-palpable
C. The mother feels the urge to push again
D. Fetal heart tones are audible on the Doppler
A. A sudden gush of blood and lengthening of the umbilical cord
Rationale: Placental separation is typically signaled by a gush of blood, lengthening of the umbilical cord, and changes in the uterine shape.
What is the primary benefit of skin-to-skin contact between the mother and newborn during the third stage of labor?
A. Decreases maternal blood loss
B. Accelerates placental separation
C. Prevents uterine inversion
D. Facilitates the newborn’s transition to extrauterine life
D. Facilitates the newborn’s transition to extrauterine life
Rationale: Skin-to-skin contact promotes thermoregulation, bonding, and adaptation of the newborn to extrauterine life.
What is a key component of active management of the third stage of labor?
A. Allowing the placenta to deliver naturally without intervention
B. Administering a uterotonic agent and performing controlled cord traction
C. Massaging the uterus before placental expulsion
D. Avoiding fundal massage to reduce maternal discomfort
B. Administering a uterotonic agent and performing controlled cord traction
Rationale: Active management involves administering a uterotonic, controlled cord traction, and uterine fundal massage after placental expulsion to prevent postpartum hemorrhage.
Which complication is most commonly associated with the third stage of labor?
A. Uterine rupture
B. Shoulder dystocia
C. Amniotic fluid embolism
D. Postpartum hemorrhage
D. Postpartum hemorrhage
Rationale: Postpartum hemorrhage is the most common complication during the third stage of labor and can be life-threatening without prompt intervention.
Which of the following statements about expectant management of the third stage of labor is correct?
A. It involves immediate administration of a uterotonic agent.
B. The placenta is delivered naturally without controlled cord traction.
C. Fundal massage is performed continuously until the placenta delivers.
D. It is more effective than active management in preventing hemorrhage.
B. The placenta is delivered naturally without controlled cord traction.
Rationale: Expectant management allows the placenta to deliver naturally without interventions such as controlled cord traction or uterotonic administration.
What is the nurse’s priority action if the uterus fails to contract after placental expulsion?
A. Reassess the placenta for completeness
B. Notify the provider and prepare for surgical intervention
C. Perform vigorous uterine fundal massage
D. Administer a second dose of a uterotonic agent as prescribed
C. Perform vigorous uterine fundal massage
Rationale: Uterine fundal massage stimulates contraction of the uterus and is a critical initial intervention to control bleeding and prevent uterine atony.
Which clinical finding indicates that the placenta is ready to deliver?
A. The uterus becomes soft and non-palpable.
B. The umbilical cord shortens and retracts.
C. The uterus changes its shape to globular.
D. The maternal blood pressure drops suddenly.
C. The uterus changes its shape to globular.
Rationale: A globular-shaped uterus, along with upward rising of the uterus, cord lengthening, and a sudden trickle of blood, are all signs that the placenta has separated from the uterine wall and is ready to deliver.
What is the distinguishing feature of a placenta delivered by the Schultz mechanism?
A. The placenta delivers spontaneously without uterine contractions.
B. The red, raw maternal side presents first.
C. The umbilical cord detaches during delivery.
D. The shiny, gray fetal side presents first.
D. The shiny, gray fetal side presents first.
Rationale: In the Schultz mechanism, the fetal side (shiny gray) of the placenta delivers first, while the Duncan mechanism involves the maternal side (red raw) delivering first.
Which of the following interventions is the priority during placental delivery?
A. Monitoring for signs of incomplete placental separation.
B. Applying firm downward pressure on the fundus to expedite expulsion.
C. Pulling gently on the umbilical cord immediately after birth of the fetus.
D. Administering oxytocin before the placenta is delivered.
A. Monitoring for signs of incomplete placental separation.
Rationale: It is critical to monitor for signs of incomplete placental separation to prevent complications such as hemorrhage or retained placenta.
The maternal side of the placenta presenting first during delivery is referred to as:
A. Shiny Schultz mechanism.
B. Placental inversion.
C. Secondary placental expulsion.
D. Duncan mechanism.
D. Duncan mechanism.
Rationale: The maternal side (red and raw) of the placenta presenting first is termed the Duncan mechanism, while the fetal side (shiny and gray) is the Schultz mechanism.
What causes the placenta to separate from the uterine wall after birth of the infant?
A. Continuous uterine contractions and retraction.
B. A sudden decrease in maternal blood pressure.
C. Mechanical traction on the umbilical cord.
D. Hormonal changes reducing uterine blood supply.
A. Continuous uterine contractions and retraction.
Rationale: After the infant is born, strong uterine contractions and retraction decrease the uterine size, pulling the placenta away from the uterine wall.
What is the primary purpose of uterine massage immediately after placental expulsion?
A. To relieve maternal pain and discomfort.
B. To promote uterine contraction and prevent hemorrhage.
C. To facilitate the birth of any remaining fetal tissue.
D. To promote the passage of urine.
B. To promote uterine contraction and prevent hemorrhage.
Rationale: Uterine massage is performed to help the uterus contract, which constricts blood vessels and reduces the risk of postpartum hemorrhage.
Which of the following is considered a normal blood loss for a vaginal birth?
A. 500 mL
B. 1,000 mL
C. 1,500 mL
D. 2,000 mL
A. 500 mL
Rationale: Normal blood loss during a vaginal birth is typically around 500 mL, with up to 1,000 mL considered normal for a cesarean birth.
What is the potential risk if any portion of the placenta remains attached to the uterine wall after expulsion?
A. Preterm labor.
B. Postpartum hemorrhage.
C. Uterine rupture.
D. Eclampsia.
B. Postpartum hemorrhage.
Rationale: Retained placental tissue can interfere with uterine contractions, leading to postpartum hemorrhage due to failure of the uterus to contract fully.
When is external traction typically used during placental expulsion?
A. Only when the placenta fails to separate.
B. After the first hour of the third stage of labor.
C. In the case of a cesarean delivery to assist with placental removal.
D. Immediately after the birth of the fetus regardless of placental separation.
A. Only when the placenta fails to separate.
Rationale: External traction is used only if the placenta fails to separate spontaneously, assisting with its expulsion in a timely manner.
What is considered severe blood loss after a vaginal birth?
A. 200 mL
B. 500 mL
C. 750 mL
D. 1,000 mL
D. 1,000 mL
Rationale: Severe blood loss is defined as greater than 1,000 mL following vaginal birth, which increases the risk of complications such as hypovolemic shock.
How long after the birth of the newborn should the placenta typically be expelled?
A. Within 1 to 5 minutes
B. Within 10 to 15 minutes
C. Within 2 to 30 minutes
D. Within 1 hour
C. Within 2 to 30 minutes
Rationale: The placenta is typically expelled within 2 to 30 minutes following birth, depending on whether external traction is used or the placenta delivers spontaneously.
What would be the most likely intervention if the placenta does not expel within the expected time frame?
A. Manual extraction by the healthcare provider.
B. Immediate administration of oxytocin.
C. External rotation of the placenta.
D. Allowing the placenta to remain for an additional hour.
A. Manual extraction by the healthcare provider.
Rationale: If the placenta does not expel within the normal time frame, manual extraction by the healthcare provider is necessary to prevent complications such as hemorrhage.
Which of the following actions should be taken if the uterus becomes boggy in the fourth stage of labor?
A. Administer an analgesic to the mother.
B. Perform manual extraction of the placenta.
C. Massage the fundus to encourage firm contraction.
D. Immediately perform a cesarean section.
C. Massage the fundus to encourage firm contraction.
Rationale: If the uterus becomes boggy (soft), the nurse should massage the fundus to encourage uterine contraction, which helps prevent postpartum hemorrhage.
During the fourth stage of labor, what is a common sign of uterine atony (boggy uterus)?
A. Excessive maternal thirst.
B. A firm and midline fundus.
C. A soft, non-contracted fundus.
D. Bright red lochia.
C. A soft, non-contracted fundus.
Rationale: A boggy uterus, which is soft and not well-contracted, is a sign of uterine atony, a risk factor for postpartum hemorrhage.
What should be the nurse’s primary focus during the fourth stage of labor?
A. To educate the mother about newborn care.
B. To monitor for complications such as hemorrhage, bladder distention, and venous thrombosis.
C. To begin prenatal care for the next pregnancy.
D. To encourage the mother to walk and move around immediately.
B. To monitor for complications such as hemorrhage, bladder distention, and venous thrombosis.
Rationale: The primary focus during the fourth stage is to monitor the mother closely for complications, including hemorrhage, bladder distention, and venous thrombosis.
What is the typical location of the fundus in the first hour after birth during the fourth stage of labor?
A. Below the symphysis pubis.
B. At the level of the umbilicus.
C. Midline between the umbilicus and the symphysis.
D. Above the umbilicus.
B. At the level of the umbilicus.
Rationale: In the first hour after birth, the fundus typically rises to the level of the umbilicus, and its position is monitored for signs of uterine atony.
Which of the following is a common maternal symptom during the fourth stage of labor due to uterine contraction?
A. Severe headache.
B. Chest pain.
C. Cramp-like discomfort.
D. Abdominal bloating.
C. Cramp-like discomfort.
Rationale: Cramp-like discomfort is common during the fourth stage of labor as the uterus contracts to its pre-pregnancy size.
What is the typical characteristic of lochia in the fourth stage of labor?
A. Clear and watery with no clots.
B. Red in color, mixed with small clots, and of moderate flow.
C. Yellow with a strong odor.
D. Greenish with heavy flow and large clots.
B. Red in color, mixed with small clots, and of moderate flow.
Rationale: Lochia during the fourth stage is typically red, mixed with small clots, and has moderate flow as the body expels the remaining blood and tissue from the uterus.
What vital signs should be monitored most frequently during the fourth stage of labor, especially within the first hour?
A. Blood pressure and temperature.
B. Heart rate and respiratory rate.
C. Blood pressure, heart rate, and temperature.
D. Blood pressure, heart rate, and fundus status.
D. Blood pressure, heart rate, and fundus status.
Rationale: Vital signs, including blood pressure, heart rate, and fundus status, should be monitored every 15 minutes during the first hour after birth to assess for complications.
Why might a woman feel hungry and thirsty during the fourth stage of labor?
A. Due to dehydration from labor.
B. Because of the effect of epidural anesthesia.
C. Due to the physical exertion of labor and delivery.
D. Due to an increased metabolic rate.
C. Due to the physical exertion of labor and delivery.
Rationale: The woman may feel hungry and thirsty after the physical exertion of labor and delivery, as the body requires energy to recover and stabilize after birth.
Which of the following hormonal changes is primarily responsible for the onset of labor?
A. Decrease in estrogen levels.
B. Decrease in progesterone levels.
C. Increase in progesterone levels.
D. Increase in testosterone levels.
B. Decrease in progesterone levels.
Rationale: The onset of labor is associated with a decrease in progesterone levels and an increase in estrogen and prostaglandins, which stimulate uterine contractions.
The most reliable sign that a woman is in active labor is:
A. Increased maternal anxiety.
B. Regular uterine contractions.
C. Complete effacement of the cervix.
D. Significant cervical change.
D. Significant cervical change.
Rationale: The most reliable sign of active labor is significant cervical change, which indicates that labor is progressing toward full dilation.
During the second stage of labor, what is the primary goal for the mother?
A. To focus on relaxation techniques.
B. To begin the process of pushing to deliver the baby.
C. To rest and conserve energy.
D. To monitor for signs of infection.
B. To begin the process of pushing to deliver the baby.
Rationale: The second stage of labor focuses on pushing and moving the fetus through the birth canal until the baby is born.
What is the primary focus during the third stage of labor?
A. Expulsion of the placenta.
B. Maternal recovery and rest.
C. Monitoring fetal heart tones.
D. Initiation of breastfeeding.
A. Expulsion of the placenta.
Rationale: The third stage of labor focuses on the expulsion of the placenta, ensuring it is fully delivered and the uterus contracts properly to minimize bleeding.
In the fourth stage of labor, which of the following is the priority nursing action for the mother during the first 1-4 hours postpartum?
A. Encourage bonding with the newborn.
B. Assess for signs of infection.
C. Begin education on newborn care.
D. Monitor for postpartum hemorrhage.
D. Monitor for postpartum hemorrhage.
Rationale: The priority action during the fourth stage is to monitor for postpartum hemorrhage, ensuring the uterus remains firm and contractions are effective in reducing bleeding.
Which stage of labor is characterized by the cervix dilating from full dilation to the birth of the infant?
A. First stage.
B. Second stage.
C. Third stage.
D. Fourth stage.
B. Second stage.
Rationale: The second stage of labor begins at full dilation and ends with the birth of the infant. This stage involves pushing and the descent of the fetus through the birth canal.
Which of the following Bishop scores indicates the highest likelihood of achieving a successful vaginal birth without the need for cervical ripening methods?
A. 3
B. 5
C. 7
D. 8
D. 8
Rationale: A Bishop score of over 8 indicates a high likelihood of a successful vaginal birth without the need for cervical ripening methods.
When a Bishop score is less than 6, what is typically indicated for the woman prior to labor induction?
A. Administration of a uterotonic agent.
B. Immediate cesarean delivery.
C. Use of cervical ripening methods.
D. Continuous fetal heart rate monitoring
C. Use of cervical ripening methods.
Rationale: A Bishop score less than 6 generally indicates the need for cervical ripening methods before induction of labor to improve the chances of a successful vaginal birth.
Which of the following components is NOT part of medical induction of labor?
A. Cervical ripening.
B. Induction of contractions.
C. Pelvic rest.
D. Evaluation of cervical readiness (Bishop score).
C. Pelvic rest.
Rationale: Pelvic rest is not a component of medical induction of labor. The two primary components are cervical ripening and induction of contractions, with cervical readiness evaluated through a Bishop score.
A 36-week pregnant patient is being assessed for induction of labor. Her Bishop score reveals the following:
Dilation: 2 cm, Effacement: 50%, Station: -2, Cervical Consistency: Medium, Position of Cervix: Midposition. What is her total Bishop score?
A. 3
B. 5
C. 7
D. 9
B. 5
Rationale: The patient’s Bishop score is calculated as follows: - Dilation (1–2 cm): 1 point - Effacement (40–50%): 1 point - Station (-2): 1 point - Cervical consistency (Medium): 1 point - Position of cervix (Midposition): 1 point Total = 5 points.
A Bishop score of less than 6 indicates which of the following?
A. Cervix is favorable for induction
B. Cervix is unfavorable for induction
C. The patient is in active labor
D. Immediate delivery is necessary
B. Cervix is unfavorable for induction
Rationale: A Bishop score less than 6 indicates an unfavorable cervix, suggesting that cervical ripening interventions may be necessary before induction of labor.
Which component of the Bishop scoring system assesses the location of the presenting part in relation to the ischial spines?
A. Effacement
B. Dilation
C. Cervical Consistency
D. Station
D. Station
Rationale: Station refers to the position of the presenting part of the fetus (e.g., head) relative to the ischial spines of the pelvis. It ranges from -3 (high in the pelvis) to +2 (near delivery).
A Bishop score of 8 or higher suggests which of the following? (SATA)
A. Increased likelihood of successful induction
B. Cervix is ripened
C. A Cesarean section is required
D. Patient is ready for labor induction
A. Increased likelihood of successful induction
B. Cervix is ripened
D. Patient is ready for labor induction
Rationale: A score of 8 or higher indicates the cervix is favorable for induction, with a high chance of a successful vaginal delivery.
A patient at 40 weeks of gestation has a Bishop score of 4. What intervention is most appropriate before initiating labor induction?
A. Administering oxytocin
B. Performing an amniotomy
C. Administering cervical ripening agents
D. Encouraging ambulation
C. Administering cervical ripening agents
Rationale: A Bishop score of 4 indicates an unfavorable cervix. Cervical ripening agents, such as prostaglandins, are typically used to soften and prepare the cervix for induction.
Which station measurement is assigned 2 points on the Bishop scoring system?
A. -3
B. -1
C. 0
D. +1
D. +1
Rationale: A station of +1 or +2 is assigned 2 points on the Bishop scoring system, indicating that the presenting part is low in the pelvis.
A patient is evaluated with the following cervical findings:
Dilation: 4 cm, Effacement: 80%, Station: +1, Cervical Consistency: Soft, Position of Cervix: Anterior. What is her Bishop score?
A. 6
B. 9
C. 11
D. 12
C. 11
Rationale: The patient’s Bishop score is calculated as follows: - Dilation (3–4 cm): 2 points - Effacement (80%): 3 points - Station (+1): 2 points - Cervical consistency (Soft): 2 points - Position of cervix (Anterior): 2 points Total = 11 points.
Which of the following findings would result in the lowest possible Bishop score?
A. Dilation: Closed, Effacement: 0–30%, Station: -3, Cervical Consistency: Firm, Position of Cervix: Posterior
B. Dilation: 1–2 cm, Effacement: 60–70%, Station: 0, Cervical Consistency: Medium, Position of Cervix: Midposition
C. Dilation: 3–4 cm, Effacement: 40–50%, Station: -1, Cervical Consistency: Soft, Position of Cervix: Anterior
D. Dilation: 5–6 cm, Effacement: 80%, Station: +2, Cervical Consistency: Very Soft, Position of Cervix: Anterior
A. Dilation: Closed, Effacement: 0–30%, Station: -3, Cervical Consistency: Firm, Position of Cervix: Posterior
Rationale: These findings (closed dilation, 0–30% effacement, -3 station, firm cervix, and posterior position) result in the lowest possible Bishop score of 0.
Cervical consistency changes during labor. Which consistency scores the highest on the Bishop scoring system?
A. Firm
B. Medium
C. Soft
D. Very soft
D. Very soft
Rationale: A “Very soft” cervix is assigned the highest score (3 points) for cervical consistency in the Bishop scoring system.
A Bishop score includes cervical dilation as a parameter. What score is given for a dilation of 5 cm?
A. 0
B. 1
C. 2
D. 3
D. 3
Rationale: A dilation of 5–6 cm scores 3 points in the Bishop scoring system.
A nulliparous patient is evaluated for labor induction. What is the minimum Bishop score required to indicate a favorable cervix?
A. 3
B. 5
C. 6
D. 8
C. 6
Rationale: A Bishop score of at least 6 is generally considered favorable for labor induction in nulliparous patients.
A Bishop score includes the position of the cervix. What score is assigned to an anterior cervix?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: An anterior cervix scores 2 points in the Bishop scoring system.
Which cervical finding correlates with the maximum possible Bishop score for effacement?
A. 0–30%
B. 40–50%
C. 60–70%
D. 80%
D. 80%
Rationale: An effacement of 80% scores the maximum of 3 points for this parameter in the Bishop scoring system.
A patient is 39 weeks pregnant with a Bishop score of 9. What does this suggest about labor induction?
A. Induction is unlikely to succeed
B. The cervix is ripened and favorable for induction
C. A Cesarean section is necessary
D. Cervical ripening agents are required
B. The cervix is ripened and favorable for induction
Rationale: A score of 9 indicates a highly favorable cervix, with a high likelihood of successful labor induction.
Which components are included in the Bishop scoring system? (SATA)
A. Cervical dilation
B. Fetal heart rate
C. Effacement
D. Station
E. Position of cervix
A. Cervical dilation
C. Effacement
D. Station
E. Position of cervix
Rationale: The Bishop scoring system evaluates cervical dilation, effacement, station, cervical consistency, and position of the cervix to assess readiness for labor induction. Fetal heart rate is not included.
Which cervical characteristics indicate that a cervix is ripe for labor induction?
A. Long, firm, and posterior.
B. Closed, soft, and posterior.
C. Shortened, softened, and anterior.
D. Long, closed, and anterior.
C. Shortened, softened, and anterior.
Rationale: A ripe cervix is described as shortened, softened, and anterior. These changes increase the likelihood of successful labor induction and vaginal birth.
What does a Bishop score of less than 6 indicate?
A. The need for cervical ripening before induction of labor.
B. The need for immediate delivery via cesarean section.
C. A high likelihood of spontaneous labor.
D. The absence of cervical effacement.
A. The need for cervical ripening before induction of labor.
Rationale: A Bishop score of less than 6 suggests the cervix is unfavorable and indicates the need for cervical ripening before labor induction to increase the chances of a successful vaginal delivery.
Which of the following best describes the purpose of cervical ripening prior to labor induction?
A. To initiate uterine contractions.
B. To allow for collagen breakdown, softening, and elasticity of the cervix.
C. To prevent premature labor.
D. To reduce the risk of postpartum hemorrhage.
B. To allow for collagen breakdown, softening, and elasticity of the cervix.
Rationale: Cervical ripening involves the breakdown of collagen, leading to cervical softening, elasticity, and distensibility, which are necessary for cervical dilation and effacement.
Which method is NOT typically used for cervical ripening?
A. Mechanical dilation using a Foley catheter.
B. Pharmacologic agents such as prostaglandins.
C. Continuous fetal monitoring.
D. Membrane sweeping.
C. Continuous fetal monitoring.
Rationale: Continuous fetal monitoring is used during labor but is not a method for cervical ripening. Mechanical and pharmacologic methods, as well as membrane sweeping, are commonly used for this purpose.
A nurse is assessing a patient with a Bishop score of 9. What conclusion can the nurse make based on this score?
A. Cervical ripening methods are required before induction.
B. The cervix is unfavorable for induction.
C. A successful vaginal birth is likely.
D. The patient is in active labor.
C. A successful vaginal birth is likely.
Rationale: A Bishop score of 8 or higher indicates a ripe cervix, suggesting a high likelihood of a successful vaginal birth without additional cervical ripening methods.
What is the primary goal of mechanical cervical ripening methods?
A. To reduce uterine contractions.
B. To increase the levels of progesterone.
C. To promote the descent of the fetus into the pelvis.
D. To apply continuous pressure to the cervix to stimulate effacement and dilation.
D. To apply continuous pressure to the cervix to stimulate effacement and dilation.
Rationale: Mechanical methods, such as the insertion of a Foley catheter, apply continuous pressure to the cervix to promote effacement and dilation.
Which hormonal change contributes to cervical ripening?
A. Increased progesterone.
B. Increased estrogen and prostaglandins.
C. Decreased estrogen and increased oxytocin.
D. Increased oxytocin and progesterone.
B. Increased estrogen and prostaglandins.
Rationale: Cervical ripening is facilitated by hormonal changes, including increased levels of estrogen and prostaglandins, which lead to collagen breakdown and softening of the cervix.
A patient undergoing induction of labor has a Bishop score of 4. What action should the nurse anticipate?
A. Starting oxytocin immediately.
B. Preparing the patient for a cesarean section.
C. Administering a cervical ripening agent.
D. Monitoring the patient for signs of spontaneous labor.
C. Administering a cervical ripening agent.
Rationale: A Bishop score of less than 6 indicates that the cervix is unripe, and cervical ripening agents should be used before initiating labor induction to improve the chances of a successful vaginal birth.
Which statement about the use of nonpharmacologic methods for cervical ripening is accurate?
A. Evening primrose oil and red raspberry leaves are scientifically proven to induce labor safely.
B. Nonpharmacologic methods such as castor oil and enemas have been thoroughly evaluated for efficacy.
C. Nonpharmacologic methods for cervical ripening lack scientific validation for safety and efficacy.
D. Nurses should discourage clients from discussing complementary and alternative methods
C. Nonpharmacologic methods for cervical ripening lack scientific validation for safety and efficacy.
Rationale: Nonpharmacologic methods such as herbal agents, castor oil, and enemas have not been scientifically evaluated for their safety or efficacy in cervical ripening or labor induction.
Which component of sexual intercourse is thought to contribute to cervical ripening?
A. Relaxation of pelvic muscles.
B. Prostaglandins found in semen.
C. Increased oxytocin released from emotional bonding.
D. Decreased uterine pressure.
B. Prostaglandins found in semen.
Rationale: Human semen contains prostaglandins, which can aid in cervical ripening.
What is a potential benefit of breast stimulation as a complementary method for labor induction?
A. It increases endorphin levels.
B. It promotes uterine relaxation.
C. It stimulates the release of oxytocin.
D. It reduces pain perception during contractions.
C. It stimulates the release of oxytocin.
Rationale: Breast stimulation promotes the release of oxytocin, which can lead to uterine contractions.
A nurse is caring for a client interested in using castor oil for labor induction. What is the most appropriate nursing response?
A. “Castor oil is a proven method to induce labor effectively.”
B. “There are no risks associated with using castor oil.”
C. “The safety and effectiveness of castor oil for labor induction have not been scientifically validated.”
D. “Castor oil is recommended by the American College of Obstetricians and Gynecologists for labor induction.”
C. “The safety and effectiveness of castor oil for labor induction have not been scientifically validated.”
Rationale: Castor oil is a nonpharmacologic method whose safety and effectiveness for labor induction have not been validated scientifically.
Which method for labor induction is associated with oxytocin release and prostaglandin exposure?
A. Sexual intercourse with breast stimulation.
B. Enemas.
C. Hot baths.
D. Evening primrose oil.
A. Sexual intercourse with breast stimulation.
Rationale: Sexual intercourse releases prostaglandins in semen, while breast stimulation promotes oxytocin release, both of which aid in labor induction.
What should a nurse emphasize when educating a client about complementary methods of labor induction?
A. These methods are safe and effective for all clients.
B. Risks and benefits of these methods are well-studied and scientifically supported.
C. Complementary methods should always replace pharmacologic induction methods.
D. Clients should discuss the use of any complementary methods with their healthcare provider.
D. Clients should discuss the use of any complementary methods with their healthcare provider.
Rationale: Clients should be advised to consult their healthcare provider regarding the use of complementary methods to ensure safety and appropriate care.
According to a Cochrane review, what is a possible outcome of sexual intercourse with breast stimulation as a labor induction method?
A. Shortened latent phase of labor.
B. Complete dilation of the cervix.
C. Elimination of labor pain.
D. Immediate onset of active labor.
A. Shortened latent phase of labor.
Rationale: The Cochrane review found that sexual intercourse with breast stimulation may shorten the latent phase of labor, although safety issues have not been fully evaluated.
A client asks if red raspberry leaves can be used to induce labor. What should the nurse include in the response?
A. “Red raspberry leaves have been scientifically proven to ripen the cervix.”
B. “The use of red raspberry leaves is safe for everyone and does not require provider consultation.”
C. “The risks and benefits of red raspberry leaves for labor induction are not well-documented.”
D. “This method is a standard practice in labor induction.”
C. “The risks and benefits of red raspberry leaves for labor induction are not well-documented.”
Rationale: The risks and benefits of herbal agents like red raspberry leaves have not been scientifically studied, so they cannot be recommended for labor induction.
Which statement about the loss of the mucus plug during pregnancy is correct?
A. Loss of the mucus plug always indicates the onset of active labor.
B. The mucus plug acts as a barrier to prevent infections in the cervix.
C. Once the mucus plug is lost, it cannot regenerate.
D. The mucus plug is expelled only during delivery.
B. The mucus plug acts as a barrier to prevent infections in the cervix.
Rationale: The mucus plug is a jelly-like barrier in the cervix that helps prevent infections. Its loss does not necessarily indicate imminent labor, and it can regenerate.
What should a nurse include when educating a pregnant client about the loss of the mucus plug?
A. “The loss of the mucus plug is a definitive sign of active labor.”
B. “The mucus plug cannot be replaced once lost, so you should go to the hospital immediately.”
C. “The loss of the mucus plug is normal and does not mean labor will start right away.”
D. “You should contact your healthcare provider immediately after losing the mucus plug.”
C. “The loss of the mucus plug is normal and does not mean labor will start right away.”
Rationale: Losing the mucus plug is a normal part of pregnancy and does not necessarily mean labor is imminent, as the cervix may still take time to prepare for delivery.
Which of the following accurately describes the purpose of membrane stripping as a surgical method to induce labor?
A. To increase uterine contractions by direct stimulation of the uterine wall
B. To detach the amniotic membranes from the cervix to promote cervical ripening
C. To rupture the membranes and expose the cervix to amniotic fluid
D. To decrease prostaglandin levels and reduce labor duration
B. To detach the amniotic membranes from the cervix to promote cervical ripening
Rationale: Membrane stripping involves manual detachment of the amniotic membranes from the cervix to encourage cervical ripening and labor onset.
Which client is at greatest risk for complications following an amniotomy?
A. A client with a breech presentation
B. A client with a Bishop score of 9
C. A client in the latent phase of labor with intact membranes
D. A client with a history of rapid labor
A. A client with a breech presentation
Rationale: Breech presentation increases the risk of umbilical cord prolapse after an amniotomy, making it a contraindication for the procedure.
What is the primary reason for monitoring the fetal heart rate (FHR) immediately following an amniotomy?
A. To identify maternal infection
B. To detect umbilical cord prolapse or compression
C. To determine the duration of labor
D. To evaluate the mother’s tolerance to the procedure
B. To detect umbilical cord prolapse or compression
Rationale: FHR monitoring after an amniotomy is crucial to detect umbilical cord prolapse or compression, which can cause FHR deceleration and jeopardize fetal oxygenation.
Which finding in the amniotic fluid after an amniotomy should prompt immediate notification of the healthcare provider?
A. Clear fluid with a mild odor
B. Blood-streaked fluid
C. Meconium-stained fluid
D. A volume of 500 mL of fluid
C. Meconium-stained fluid
Rationale: Meconium-stained fluid may indicate fetal distress, requiring immediate assessment and intervention to ensure fetal well-being.
What is the most significant risk associated with membrane stripping?
A. Fetal heart rate decelerations
B. Umbilical cord prolapse
C. Maternal or neonatal infection
D. Incomplete placental separation
C. Maternal or neonatal infection
Rationale: Membrane stripping increases the risk of introducing pathogens into the uterus, potentially leading to maternal or neonatal infection.
A nurse is assisting during an amniotomy. Which of the following actions is most critical immediately after the procedure?
A. Administering a uterotonic medication
B. Evaluating maternal discomfort levels
C. Monitoring uterine contraction frequency
D. Assessing fetal heart rate and amniotic fluid characteristics
D. Assessing fetal heart rate and amniotic fluid characteristics
Rationale: After an amniotomy, the nurse must immediately assess the FHR for signs of umbilical cord prolapse or compression and evaluate the amniotic fluid for characteristics indicating complications.
Which prostaglandin agent is FDA-approved for cervical ripening?
A. Dinoprostone (Cervidil)
B. Misoprostol (Cytotec)
C. Oxytocin (Pitocin)
D. Carboprost (Hemabate)
A. Dinoprostone (Cervidil)
Rationale: Dinoprostone (Cervidil) is the only FDA-approved agent for cervical ripening. Misoprostol, while effective, is not FDA-approved for this purpose but is endorsed by ACOG due to its safety and effectiveness.
Which maternal history contraindicates the use of misoprostol (Cytotec) for cervical ripening?
A. Gestational diabetes
B. Previous uterine scar
C. Preterm labor
D. Placenta previa
B. Previous uterine scar
Rationale: Misoprostol is contraindicated for women with prior uterine scars, such as those from a cesarean section, because it increases the risk of uterine rupture.
What is the major adverse effect associated with prostaglandin agents used for cervical ripening?
A. Uterine hyperstimulation
B. Increased risk of infection
C. Delayed cervical ripening
D. Fetal bradycardia
A. Uterine hyperstimulation
Rationale: Prostaglandins can induce excessive uterine contractions, leading to uterine hyperstimulation. This can impair uteroplacental blood flow, increase perinatal morbidity, and potentially lead to uterine rupture.
What is the most appropriate initial dose of misoprostol (Cytotec) for cervical ripening?
A. 25 to 50 mcg
B. 75 to 100 mcg
C. 100 to 200 mcg
D. 10 to 20 mcg
A. 25 to 50 mcg
Rationale: Misoprostol is typically administered at doses of 25 to 50 mcg for cervical ripening. Higher doses increase the risk of uterine hyperstimulation and related complications.
Why is misoprostol not FDA-approved for cervical ripening, despite being widely used?
A. Lack of clinical evidence for its effectiveness
B. High incidence of uterine rupture
C. Its primary indication is gastric ulcer prevention
D. It requires specific administration techniques
C. Its primary indication is gastric ulcer prevention
Rationale: Misoprostol was initially developed and FDA-approved for gastric ulcer prevention. Although it is effective for cervical ripening, its use for this purpose is considered off-label.
Which intervention is most important after administering a prostaglandin agent for cervical ripening?
A. Encouraging ambulation to promote cervical dilation
B. Monitoring fetal heart rate and uterine activity
C. Administering IV fluids to prevent dehydration
D. Inserting a urinary catheter to monitor output
B. Monitoring fetal heart rate and uterine activity
Rationale: Continuous monitoring of fetal heart rate and uterine activity is critical to identify adverse effects such as uterine hyperstimulation or fetal distress.
A nurse is caring for a client receiving dinoprostone gel (Prepidil). Which finding would require immediate action?
A. Mild cramping after administration
B. Cervical dilation of 2 cm
C. Maternal temperature of 99°F
D. Uterine contractions every 2 minutes lasting 90 seconds
D. Uterine contractions every 2 minutes lasting 90 seconds
Rationale: Uterine contractions every 2 minutes lasting 90 seconds indicate uterine hyperstimulation, which can compromise uteroplacental blood flow and lead to fetal distress. Immediate action is required.
Which statement by the nurse demonstrates understanding of prostaglandin use for cervical ripening?
A. “Misoprostol is safe for all women, regardless of obstetric history.”
B. “Dinoprostone is FDA-approved and has minimal risks of adverse effects.”
C. “The primary advantage of prostaglandins is preventing uterine contractions.”
D. “Prostaglandins promote cervical changes and may initiate labor contractions.”
D. “Prostaglandins promote cervical changes and may initiate labor contractions.”
Rationale: Prostaglandins are used for cervical ripening as they promote cervical changes and can stimulate uterine contractions. However, they carry risks such as uterine hyperstimulation.
A nurse observes that uterine contractions have increased in frequency and duration with oxytocin administration. What action should the nurse take first?
A. Stop the oxytocin infusion
B. Increase IV fluids
C. Notify the provider
D. Reposition the client to the left side
A. Stop the oxytocin infusion
Rationale: If uterine hyperstimulation is suspected, the nurse’s first action is to stop the oxytocin infusion to allow the uterus to relax and prevent further fetal compromise. Then, additional interventions can be initiated, such as repositioning and notifying the provider.
Why should oxytocin be titrated cautiously during labor?
A. To prevent prolonged labor
B. To reduce the risk of maternal infection
C. To minimize uterine hyperstimulation and fetal compromise
D. To avoid amniotic fluid embolism
C. To minimize uterine hyperstimulation and fetal compromise
Rationale: Oxytocin must be carefully titrated to minimize the risk of uterine hyperstimulation, which can compromise fetal oxygenation and increase maternal and perinatal morbidity.
What is the typical goal of oxytocin infusion during labor?
A. Continuous uterine contractions lasting 90 seconds
B. Contractions every 2 to 3 minutes lasting 40 to 60 seconds
C. Resting uterine tone above 30 mm Hg
D. Rapid cervical dilation within 1 hour
B. Contractions every 2 to 3 minutes lasting 40 to 60 seconds
Rationale: The goal is to achieve stable contractions every 2 to 3 minutes, each lasting 40 to 60 seconds, allowing for adequate uterine relaxation and fetal oxygenation between contractions.
Which characteristic of oxytocin makes it an effective agent for labor induction?
A. Long half-life of 12 hours
B. Ability to cross the placental barrier
C. Potent, short-acting, and easily titratable
D. Safe for use without monitoring
C. Potent, short-acting, and easily titratable
Rationale: Oxytocin is effective because of its potency, short half-life (1 to 5 minutes), and ease of titration. It is generally well tolerated but requires continuous monitoring due to potential side effects.
Which finding during oxytocin administration requires immediate action?
A. Uterine contractions every 3 minutes lasting 45 seconds
B. Resting uterine tone above 20 mm Hg
C. Clear amniotic fluid
D. Maternal blood pressure of 120/80 mm Hg
B. Resting uterine tone above 20 mm Hg
Rationale: Resting uterine tone above 20 mm Hg can indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate intervention to reduce oxytocin dosage.
What is the primary reason for administering prostaglandins before oxytocin in women with low Bishop scores?
A. To prevent uterine rupture
B. To shorten the duration of labor
C. To decrease the risk of water intoxication
D. To promote cervical ripening and increase the likelihood of successful induction
D. To promote cervical ripening and increase the likelihood of successful induction
Rationale: Prostaglandins are used to ripen the cervix in women with low Bishop scores, significantly enhancing the success of labor induction with oxytocin.
Which symptom indicates water intoxication, a potential side effect of oxytocin?
A. Hypertension and tachycardia
B. Headache and vomiting
C. Bradycardia and diaphoresis
D. Dry mouth and constipation
B. Headache and vomiting
Rationale: Water intoxication due to oxytocin’s antidiuretic effect can result in symptoms such as headache and vomiting.
What is a critical nursing intervention during oxytocin administration?
A. Encourage the patient to void every 30 minutes
B. Maintain the patient in a supine position
C. Discontinue IV fluids to prevent fluid overload
D. Monitor fetal heart rate and uterine activity continuously
D. Monitor fetal heart rate and uterine activity continuously
Rationale: Continuous monitoring of FHR and uterine activity is necessary to identify complications such as uterine hyperstimulation or fetal hypoxia.
How is oxytocin administered during labor induction?
A. Intramuscular injection in the gluteal muscle
B. Intravenous infusion pump piggybacked into the main IV line
C. Subcutaneous injection every 4 hours
D. Oral tablets given every 2 hours
B. Intravenous infusion pump piggybacked into the main IV line
Rationale: Oxytocin is administered via an IV infusion pump, piggybacked into the main intravenous line at the port closest to the insertion site. This allows for precise titration of the medication.
What is the most common adverse effect of oxytocin administration?
A. Uterine rupture
B. Hypotension
C. Uterine hyperstimulation
D. Water intoxication
C. Uterine hyperstimulation
Rationale: The most common adverse effect of oxytocin is uterine hyperstimulation, which can lead to fetal compromise and impaired oxygenation. Continuous fetal heart rate (FHR) monitoring is essential to detect and address this complication.
What should the nurse assess to ensure both the client and fetus are prepared for labor induction?
A. Maternal glucose levels and fetal station
B. Amniotic fluid volume and maternal pain levels
C. Fetal movements and maternal hydration status
D. Cervical dilation, effacement, and fetal well-being
D. Cervical dilation, effacement, and fetal well-being
Rationale: Before labor induction, it is essential to assess the client’s cervical status (dilation and effacement) and ensure fetal well-being through monitoring techniques to determine readiness and the ability to tolerate labor contractions.
Which nursing intervention is essential when evaluating a client before cervical ripening?
A. Administering oxytocin before confirming fetal position
B. Measuring fetal heart tones after prostaglandin insertion
C. Scheduling a cesarean delivery for a Bishop score less than 6
D. Reviewing the client’s history for placenta previa
D. Reviewing the client’s history for placenta previa
Rationale: Rationale: Reviewing the client’s history for contraindications, such as placenta previa, is crucial to prevent complications associated with cervical ripening and labor induction.
What is the primary purpose of calculating the Bishop score before initiating labor induction?
A. To assess maternal vital signs stability
B. To determine the gestational age of the fetus
C. To predict the likelihood of a successful vaginal delivery
D. To identify signs of fetal distress
C. To predict the likelihood of a successful vaginal delivery
Rationale: The Bishop score evaluates cervical readiness for labor and helps predict the likelihood of a successful vaginal delivery. A score over 8 suggests a higher probability of success without cervical ripening.
A nurse is assessing a woman prior to labor induction. Which of the following findings would most likely indicate the need to delay the procedure?
A. Fetal station at -3
B. Bishop score of 9
C. Maternal blood pressure of 135/85 mm Hg
D. Gestational age of 41 weeks
A. Fetal station at -3
Rationale: A fetal station of -3 indicates that the presenting part is still high in the pelvis, which could decrease the likelihood of a successful induction. A low Bishop score (associated with an unfavorable cervix) may require cervical ripening before induction.
Which client history finding would contraindicate labor induction?
A. Gestational diabetes managed with insulin
B. Prolonged ruptured membranes of 24 hours
C. Active genital herpes infection
D. Post-term pregnancy at 41 weeks
C. Active genital herpes infection
Rationale: Active genital herpes infection is a contraindication for labor induction due to the risk of neonatal herpes transmission during vaginal delivery. A cesarean delivery is recommended in such cases.
What is the primary role of the nurse in ensuring informed consent for labor induction?
A. Explaining all aspects of the procedure to the client and her partner
B. Verifying the client has signed the consent form after understanding the procedure
C. Obtaining the client’s verbal agreement before starting induction
D. Determining the client’s Bishop score before obtaining consent
B. Verifying the client has signed the consent form after understanding the procedure
Rationale: The nurse ensures that the client has signed the informed consent form after receiving complete information about the procedure, including risks, benefits, and alternatives, from the healthcare provider. The nurse’s role is to verify understanding, not provide all details of the procedure.
A nurse is preparing a client for labor induction. Which statement by the nurse best explains the procedure?
A. “Labor induction ensures you will have a faster and easier delivery.”
B. “Labor induction involves using various methods to start labor due to medical reasons like high blood pressure or prolonged pregnancy.”
C. “Labor induction is always done using medications such as oxytocin to cause contractions.”
D. “Labor induction will prevent the need for a cesarean section in your case.”
B. “Labor induction involves using various methods to start labor due to medical reasons like high blood pressure or prolonged pregnancy.”
Rationale: The nurse should provide a clear and accurate explanation of labor induction, including its purpose and methods. It is often recommended for specific medical reasons such as elevated blood pressure or prolonged pregnancy.
Which nursing intervention is most important before initiating labor induction?
A. Explaining the risks of cesarean delivery to the client
B. Ensuring that the client’s vital signs are stable
C. Verifying the Bishop score has been assessed and documented
D. Determining the client’s pain tolerance level
C. Verifying the Bishop score has been assessed and documented
Rationale: Ensuring that the Bishop score has been assessed and documented is critical, as it helps predict the success of labor induction and identifies whether cervical ripening is needed.
A client undergoing labor induction asks why her provider recommended this procedure. Which reason would the nurse identify as a possible indication for labor induction?
A. Prolonged pregnancy over 41 weeks
B. Client’s desire for a specific delivery date
C. Maternal age of 35 years or older
D. History of a previous vaginal delivery
A. Prolonged pregnancy over 41 weeks
Rationale: Prolonged pregnancy beyond 41 weeks is a medical indication for labor induction to reduce risks to both the mother and fetus. Personal preference or advanced maternal age alone is not an indication for induction.
What should the nurse include in teaching about methods of labor induction?
A. “Only oxytocin is used to start labor induction.”
B. “Breaking the amniotic sac will soften the cervix.”
C. “Labor induction does not involve medications in most cases.”
D. “Stripping the membranes and using medications are common ways to induce labor.”
D. “Stripping the membranes and using medications are common ways to induce labor.”
Rationale: Stripping the membranes and using medications, such as prostaglandins or oxytocin, are common methods of labor induction. This teaching provides a comprehensive overview of possible approaches.
When preparing to administer misoprostol for cervical ripening, the nurse should ensure the client does not have which condition?
A. Hypertension
B. History of uterine scars
C. Gestational diabetes
D. Polyhydramnios
B. History of uterine scars
Rationale: Misoprostol is contraindicated in women with a history of uterine scars (e.g., from cesarean delivery) due to the increased risk of uterine rupture. Hypertension and gestational diabetes are not contraindications for misoprostol use.
Which nursing action takes priority when administering oxytocin via IV infusion?
A. Monitoring uterine resting tone frequently
B. Administering oxytocin as a primary infusion line
C. Increasing the infusion rate every 10 minutes
D. Discontinuing oxytocin if uterine contractions occur every 5 minutes
A. Monitoring uterine resting tone frequently
Rationale: Monitoring uterine resting tone is critical to ensure the uterus relaxes adequately between contractions and to prevent uteroplacental insufficiency.
Which instruction is most important for the nurse to provide a client receiving oxytocin for labor induction?
A. “Notify me if you feel excessive pressure or pain between contractions.”
B. “You may feel mild cramping as the medication begins to work.”
C. “It is normal to have a decrease in urine output during this procedure.”
D. “This medication will prevent the need for a cesarean section.”
A. “Notify me if you feel excessive pressure or pain between contractions.”
Rationale: Excessive pain or pressure between contractions may indicate uterine hyperstimulation, which requires immediate intervention. Decreased urine output is a sign of water intoxication and is not expected.
What is the expected cervical dilation rate in a client receiving oxytocin for labor induction?
A. 0.5 cm per hour
B. 1 cm per hour
C. 1.5 cm per hour
D. 2 cm per hour
B. 1 cm per hour
Rationale: Satisfactory labor progress during oxytocin administration is typically indicated by cervical dilation of approximately 1 cm per hour. Slower rates may indicate the need for reassessment of the induction plan.
The nurse adjusts the oxytocin infusion rate based on which critical maternal assessment finding?
A. Resting uterine tone
B. Cervical effacement
C. Presence of caput succedaneum
D. Estimated fetal weight
A. Resting uterine tone
Rationale: Resting uterine tone is monitored closely during oxytocin administration to ensure the uterus relaxes between contractions and prevent complications like uteroplacental insufficiency.
Which maternal and fetal assessments should be conducted every 15 minutes during the first stage of labor with oxytocin infusion?
A. Maternal oxygen saturation and fetal head position
B. Maternal vital signs and fetal heart rate
C. Maternal contractions and fetal station
D. Maternal cervical dilation and fetal presentation
B. Maternal vital signs and fetal heart rate
Rationale: Frequent monitoring of maternal vital signs and FHR ensures early identification of complications such as uterine hyperstimulation or fetal distress.
Which action by the nurse can prevent soft tissue obstruction during oxytocin administration for labor induction?
A. Encourage the client to ambulate continuously
B. Perform frequent perineal massages
C. Position the client in a high Fowler’s position
D. Encourage the client to empty her bladder every 2 hours
D. Encourage the client to empty her bladder every 2 hours
Rationale: Encouraging the client to empty her bladder every 2 hours helps prevent soft tissue obstruction and allows for optimal fetal descent.
During the active phase of labor, how frequently should the nurse document the fetal heart rate (FHR) while administering oxytocin?
A. Every 30 minutes
B. Every 20 minutes
C. Every 15 minutes
D. Every 5 minutes
C. Every 15 minutes
Rationale: Continuous FHR monitoring is critical during labor induction with oxytocin. Documentation every 15 minutes during the active phase helps ensure fetal well-being.
Which finding would require immediate discontinuation of oxytocin during labor induction?
A. Contraction duration of 60 seconds
B. Category I FHR pattern
C. Resting uterine tone of 25 mm Hg
D. Category III FHR pattern
D. Category III FHR pattern
Rationale: A category III FHR pattern indicates abnormal fetal status and requires immediate discontinuation of oxytocin to address fetal compromise.
When monitoring a client receiving oxytocin, the nurse notes uterine hyperstimulation. What is the priority nursing action?
A. Increase the oxytocin infusion rate to progress labor
B. Discontinue the oxytocin infusion and notify the healthcare provider
C. Reassess the fetal heart rate every 30 minutes
D. Administer a bolus of IV fluids to reduce uterine activity
B. Discontinue the oxytocin infusion and notify the healthcare provider
Rationale: Uterine hyperstimulation requires immediate discontinuation of oxytocin and notification of the healthcare provider to prevent fetal hypoxia and uterine rupture.
Which is the correct initial nursing action when preparing to administer oxytocin for labor induction?
A. Dilute 10 units of oxytocin in 500 mL of isotonic solution
B. Connect the oxytocin infusion to the primary line
C. Administer oxytocin as a bolus to achieve rapid labor progression
D. Set up the infusion using an IV pump and secondary line
D. Set up the infusion using an IV pump and secondary line
Rationale: Oxytocin is administered via an IV infusion pump on a secondary line to ensure precise titration and safety. Bolus administration is contraindicated as it can lead to uterine hyperstimulation.
A client receiving dinoprostone reports nausea and diarrhea. What should the nurse do first?
A. Discontinue the medication immediately
B. Reassure the client that this is a normal side effect
C. Administer an antiemetic as prescribed
D. Assess the fetal heart rate and maternal vital signs
D. Assess the fetal heart rate and maternal vital signs
Rationale: While nausea and diarrhea are known side effects of dinoprostone, the nurse should first assess maternal and fetal well-being to rule out additional complications before taking further action.
Which adverse effect should the nurse prioritize monitoring when administering oxytocin for labor induction?
A. Maternal hypotension
B. Uterine hyperstimulation
C. Neonatal hypoglycemia
D. Prolonged latent phase of labor
B. Uterine hyperstimulation
Rationale: Uterine hyperstimulation is a critical adverse effect of oxytocin that can impair uteroplacental blood flow and lead to fetal hypoxia or uterine rupture.
What is the most appropriate timing for initiating oxytocin after the administration of misoprostol?
A. Immediately after the last dose of misoprostol
B. At least 2 hours after the last dose
C. At least 4 hours after the last dose
D. The next day after administering misoprostol
C. At least 4 hours after the last dose
Rationale: Oxytocin should be initiated at least 4 hours after the last dose of misoprostol to prevent uterine hyperstimulation and adverse fetal outcomes.
A client receiving oxytocin for labor induction develops signs of water intoxication. Which symptom would the nurse expect to observe?
A. Hyperreflexia
B. Headache and vomiting
C. Hypertension and bradycardia
D. Increased urinary output
B. Headache and vomiting
Rationale: Water intoxication due to oxytocin administration can lead to headache, nausea, vomiting, and confusion due to fluid overload and hyponatremia. Hypertension and increased urinary output are not typical signs.
What is the appropriate nursing action if a client receiving misoprostol develops uterine hyperstimulation?
A. Increase the oxytocin infusion rate to promote uterine relaxation
B. Administer terbutaline to reduce uterine activity
C. Continue monitoring, as this is an expected side effect
D. Apply fundal pressure to assist with fetal descent
B. Administer terbutaline to reduce uterine activity
Rationale: Terbutaline, a tocolytic, is used to manage uterine hyperstimulation and decrease the risk of fetal hypoxia or uterine rupture. Increasing oxytocin would exacerbate hyperstimulation, and fundal pressure is contraindicated in this situation.
Which nursing intervention is most critical when administering dinoprostone for cervical ripening?
A. Administering oxytocin simultaneously with dinoprostone
B. Ensuring the client remains upright for 2 hours after insertion
C. Observing for signs of maternal hypotension
D. Monitoring maternal vital signs and fetal heart rate patterns frequently
D. Monitoring maternal vital signs and fetal heart rate patterns frequently
Rationale: Frequent monitoring of maternal vital signs and fetal heart rate patterns is essential to identify any adverse effects, such as uterine hyperstimulation or fetal compromise. Administering oxytocin simultaneously is contraindicated, and upright positioning is unnecessary for dinoprostone.
A client receiving oxytocin experiences contractions every 90 seconds lasting 90 seconds each. What is the most appropriate intervention?
A. Stop the oxytocin infusion and initiate intrauterine resuscitation
B. Continue monitoring contractions and FHR
C. Decrease the oxytocin infusion rate by 1 mu/min
D. Administer a tocolytic medication to halt contractions
A. Stop the oxytocin infusion and initiate intrauterine resuscitation
Rationale: Contractions occurring every 90 seconds with prolonged durations indicate tachysystole, which can compromise uteroplacental blood flow. The nurse must stop the oxytocin infusion and initiate interventions such as repositioning, oxygen administration, and notifying the provider.
Why is continuous fetal heart rate (FHR) monitoring required during oxytocin administration?
A. To evaluate fetal oxygenation and identify signs of distress
B. To ensure maternal comfort during contractions
C. To determine the progression of cervical dilation
D. To monitor for uterine rupture during labor
A. To evaluate fetal oxygenation and identify signs of distress
Rationale: Continuous FHR monitoring during oxytocin administration is essential to detect fetal distress, which may result from uteroplacental insufficiency caused by uterine hyperstimulation.
What is the nurse’s priority action if tachysystole is detected in a client receiving oxytocin?
A. Increase the oxytocin infusion to progress labor
B. Discontinue oxytocin infusion and notify the provider
C. Administer oxygen via nasal cannula
D. Encourage ambulation to reduce contraction frequency
B. Discontinue oxytocin infusion and notify the provider
Rationale: Tachysystole, defined as excessive uterine contractions, can impair fetal oxygenation. The oxytocin infusion should be discontinued immediately, and the provider notified to prevent complications.
The nurse starts oxytocin at 1 mu/min. According to standard protocols, how frequently should the infusion rate be increased?
A. Every 15 minutes by 2 mu/min
B. Every 20 minutes by 1 mu/min
C. Every 30 to 60 minutes by 1-2 mu/min
D. Every hour by 3 mu/min
C. Every 30 to 60 minutes by 1-2 mu/min
Rationale: Oxytocin infusions are typically increased by 1-2 mu/min every 30 to 60 minutes to achieve adequate contraction patterns without causing uterine tachysystole.
A nurse is preparing to start an oxytocin infusion for labor induction. What is the minimum Bishop score that indicates readiness for induction with oxytocin?
A. 4
B. 6
C. 8
D. 10
C. 8
Rationale: A Bishop score higher than 8 indicates the cervix is favorable for induction with oxytocin, increasing the likelihood of successful labor. Lower scores suggest the need for cervical ripening before oxytocin administration.
A client calls the nurse reporting contractions every 7 minutes lasting 30 seconds, with discomfort only in her lower abdomen. What is the best response by the nurse?
A. “These contractions sound like true labor; go to the hospital.”
B. “You are in early labor; stay home and prepare for delivery.”
C. “This is likely false labor; drink fluids and walk to see if contractions change.”
D. “Call back when contractions are 2–3 minutes apart.”
C. “This is likely false labor; drink fluids and walk to see if contractions change.”
Rationale: Contractions that are irregular, short in duration, and limited to the lower abdomen are indicative of false labor.
How should the nurse advise a client to confirm false labor at home?
A. Rest and avoid walking to minimize contractions.
B. Time contractions to confirm they occur every 4–6 minutes.
C. Assess for cervical changes using a home device.
D. Monitor contraction intensity after drinking fluids and walking.
D. Monitor contraction intensity after drinking fluids and walking.
Rationale: Drinking fluids and walking can help determine whether contractions are false, as false labor contractions often diminish with these actions.
A client reports contractions that begin in her lower back and move to her abdomen. How should the nurse interpret this information?
A. True labor is likely occurring.
B. These are signs of fetal malposition.
C. False labor contractions often behave this way.
D. The client needs immediate intervention for preterm labor.
A. True labor is likely occurring.
Rationale: Discomfort starting in the back and radiating to the abdomen is a hallmark of true labor contractions.
A nurse notes a client’s contractions are irregular and decrease in intensity with ambulation. What should the nurse conclude?
A. The client is experiencing early labor.
B. These are signs of false labor.
C. The client needs immediate medical evaluation.
D. These contractions indicate cervical dilation.
B. These are signs of false labor.
Rationale: Contractions that are irregular and diminish with ambulation are characteristic of false labor.
What should the nurse assess first when a client presents to the hospital with complaints of regular contractions?
A. Frequency, duration, and intensity of contractions
B. Cervical dilation and effacement
C. Fetal station and position
D. Client’s hydration status
A. Frequency, duration, and intensity of contractions
Rationale: Assessing contraction patterns (frequency, duration, and intensity) helps determine whether the client is in true labor, which guides further assessments and interventions.
Which characteristic is most consistent with false labor?
A. Contractions that increase in frequency over time
B. Discomfort radiating from the back to the abdomen
C. Contractions that diminish with walking or position changes
D. Contractions occurring every 5 minutes, lasting 60 seconds
C. Contractions that diminish with walking or position changes
Rationale: False labor contractions typically decrease in intensity or stop with walking, activity, or positional changes.
A client reports contractions that are 4 minutes apart and last 50 seconds but states she can talk through them. What is the nurse’s best response?
A. “You are in active labor; go to the hospital immediately.”
B. “These are Braxton Hicks contractions; drink fluids and rest.”
C. “Call your provider to discuss induction options.”
D. “Stay home until the contractions are so strong you cannot talk during one.”
D. “Stay home until the contractions are so strong you cannot talk during one.”
Rationale: Contractions in true labor become strong enough to prevent conversation during one. The client should monitor for this change before heading to the hospital.
A client in early labor asks when she should go to the hospital. Which response is most appropriate?
A. “Come in when your contractions are 10 minutes apart.”
B. “Stay home until contractions are 5 minutes apart, lasting 45–60 seconds, and strong enough that you can’t talk during one.”
C. “Go to the hospital as soon as contractions start.”
D. “Stay home unless your water breaks.”
B. “Stay home until contractions are 5 minutes apart, lasting 45–60 seconds, and strong enough that you can’t talk during one.”
Rationale: Clients in early labor are typically advised to stay home until contractions are 5 minutes apart, last 45–60 seconds, and are strong enough to limit conversation during one.
A client in her third trimester reports contractions every 5 minutes lasting 60 seconds, with severe back pain radiating to the abdomen. What is the nurse’s best advice?
A. Stay home and hydrate.
B. Take a warm bath to relax.
C. Go to the hospital or birthing center.
D. Lie down and rest to reduce contractions.
C. Go to the hospital or birthing center.
Rationale: Contractions every 5 minutes lasting 60 seconds, combined with discomfort radiating from the back to the abdomen, indicate true labor. The client should proceed to the hospital or birthing center.
What action should a nurse recommend for a client experiencing irregular contractions at 38 weeks gestation?
A. Call the health care provider immediately.
B. Go to the hospital to confirm labor onset.
C. Lie in a supine position to reduce contraction discomfort.
D. Drink fluids and ambulate to assess for changes in contraction intensity.
D. Drink fluids and ambulate to assess for changes in contraction intensity.
Rationale: Irregular contractions that diminish with hydration or activity suggest false labor. Clients can stay home and monitor for changes in intensity or regularity.
Which finding is most indicative of true labor?
A. Irregular contractions with minimal discomfort
B. Contractions felt only in the lower abdomen
C. Contractions that intensify with positional changes
D. Decreased intensity of contractions after hydration
C. Contractions that intensify with positional changes
Rationale: True labor is characterized by contractions that persist and intensify regardless of positional changes or activity.
A nurse assesses a client reporting contractions that diminish with walking and hydration. How should the nurse advise the client?
A. “You should come to the hospital immediately.”
B. “These are signs of true labor, and you should prepare for delivery.”
C. “Lie down and avoid any further activity to prevent labor progression.”
D. “Continue monitoring contractions and stay home unless they become more regular and stronger.”
D. “Continue monitoring contractions and stay home unless they become more regular and stronger.”
Rationale: False labor contractions often decrease with hydration and walking. Clients should stay home unless contractions become regular, stronger, and closer together.
A client at 39 weeks gestation calls the clinic reporting contractions every 6 minutes that last 50 seconds. What additional information should the nurse gather to determine if the client is in true labor?
A. Location of discomfort
B. Presence of vaginal discharge
C. The client’s last meal
D. Fetal movement pattern
A. Location of discomfort
Rationale: In true labor, discomfort begins in the back and radiates to the front of the abdomen. This detail helps distinguish true labor from false labor.
Which statement best differentiates true labor from false labor?
A. True labor contractions are irregular and decrease in intensity with activity.
B. False labor contractions are regular and last 45–60 seconds.
C. True labor contractions increase in strength and continue despite positional changes.
D. False labor contractions start in the back and radiate to the abdomen.
C. True labor contractions increase in strength and continue despite positional changes.
Rationale: True labor contractions become stronger with time and persist regardless of activity or positional changes. False labor contractions are irregular and diminish with activity or rest.
A client is 37 weeks pregnant and reports bright red bleeding after intercourse. How should the nurse respond?
A. “This is normal; avoid intercourse for the rest of the pregnancy.”
B. “Spotting after intercourse is normal in the third trimester.”
C. “Come to the hospital to ensure there are no complications.”
D. “Rest at home and monitor the bleeding.”
C. “Come to the hospital to ensure there are no complications.”
Rationale: Bright red bleeding after intercourse, especially late in pregnancy, could indicate a serious complication, such as placenta previa, and requires immediate evaluation.
A client at 38 weeks gestation reports that her water has broken, and she is not experiencing contractions. What should the nurse instruct her to do?
A. Come to the hospital immediately.
B. Wait at home until contractions begin.
C. Lie down and rest until contractions start.
D. Call the healthcare provider the next day.
A. Come to the hospital immediately.
Rationale: Rupture of membranes requires immediate medical attention to reduce the risk of infection and to assess for labor progression.
A client reports mild spotting after a vaginal exam. What is the appropriate nursing response?
A. Reassure the client that spotting after a vaginal exam is normal.
B. Advise the client to come to the hospital for further evaluation.
C. Instruct the client to rest and monitor for further bleeding.
D. Recommend the client increase fluid intake to reduce the spotting.
A. Reassure the client that spotting after a vaginal exam is normal.
Rationale: Spotting after a vaginal exam is common due to the sensitivity of the cervix. The nurse should reassure the client that this is a normal occurrence.
A pregnant client is experiencing severe pain in the upper abdomen, accompanied by nausea and vomiting. What is the most likely complication?
A. Preeclampsia
B. Placental abruption
C. Acute cholecystitis
D. Ectopic pregnancy
A. Preeclampsia
Rationale: Severe pain in the upper abdomen, along with nausea and vomiting, may indicate preeclampsia, a pregnancy-related condition that requires immediate medical attention.
A client at 37 weeks gestation calls the clinic and reports that her water has broken. The client is not having contractions. What should the nurse recommend?
A. “Stay home and monitor contractions; come in when they begin.”
B. “Come to the hospital immediately for evaluation and monitoring.”
C. “Try walking around to stimulate labor and monitor contractions at home.”
D. “Call your healthcare provider to schedule an induction.”
B. “Come to the hospital immediately for evaluation and monitoring.”
Rationale: Rupture of membranes requires immediate medical evaluation to reduce the risk of infection and assess for signs of labor progression.
A client who is 39 weeks pregnant reports no fetal movement for the past 6 hours. What should the nurse do first?
A. Advise the client to drink cold water and lie down for 30 minutes.
B. Tell the client to wait until the next morning to assess fetal movement.
C. Recommend a visit to the office for a routine checkup.
D. Instruct the client to come to the hospital immediately for fetal monitoring.
D. Instruct the client to come to the hospital immediately for fetal monitoring.
Rationale: No fetal movement for several hours, particularly at term, may indicate fetal distress. The client should come to the hospital immediately for further evaluation and monitoring.
A client calls the hospital and reports contractions every 5 minutes, lasting 60 seconds, but still feels able to talk during contractions. What should the nurse recommend?
A. “Come to the hospital immediately for evaluation.”
B. “Stay at home and continue to monitor your contractions.”
C. “Rest until the contractions become stronger and closer together.”
D. “Call your healthcare provider in the morning for a follow-up appointment.”
B. “Stay at home and continue to monitor your contractions.”
Rationale: Contractions that are regular but not strong enough to impair conversation typically indicate early labor. The client should stay at home and monitor the situation until contractions become stronger.
A client presents with severe headaches, vision changes, and swelling in her hands and feet. What condition should the nurse suspect?
A. Preeclampsia
B. Gestational diabetes
C. Normal pregnancy symptoms
D. Placental abruption
A. Preeclampsia
Rationale: Severe headaches, vision changes, and swelling, particularly in the hands and face, are symptoms of preeclampsia, which requires immediate medical attention.
A pregnant client at 36 weeks gestation reports bright red vaginal bleeding after intercourse. What is the most appropriate nursing action?
A. Advise the client to rest and monitor the bleeding at home.
B. Instruct the client to come to the hospital immediately for evaluation.
C. Reassure the client that this is a normal occurrence in late pregnancy.
D. Tell the client to wait until the bleeding stops and then call the doctor.
B. Instruct the client to come to the hospital immediately for evaluation.
Rationale: Bright red bleeding that is not associated with cervical sensitivity after an exam or intercourse could indicate a serious complication, such as placenta previa or abruptio placenta, and requires immediate evaluation.
A client reports decreased fetal movement, noting that the baby has moved less than 10 times in the last 2 hours when the baby is normally active. What is the nurse’s most appropriate response?
A. “It’s normal for fetal movement to decrease toward the end of pregnancy.”
B. “Try drinking some cold water and lying on your side for 30 minutes and then call me back.”
C. “Contact your healthcare provider for a follow-up appointment.”
D. “It’s important to come to the hospital immediately for fetal monitoring.”
D. “It’s important to come to the hospital immediately for fetal monitoring.”
Rationale: Decreased fetal movement, particularly when it is less than 10 movements in 2 hours, can indicate fetal distress, and the nurse should advise the client to come to the hospital for evaluation.
A client at 39 weeks gestation calls the clinic reporting that her water has broken. She is not having regular contractions. What is the best advice from the nurse?
A. “Go to the hospital immediately regardless of contractions.”
B. “Stay at home until contractions are 5 minutes apart.”
C. “Wait for contractions to begin and call when they are regular.”
D. “Lie down and rest at home until contractions become regular.”
A. “Go to the hospital immediately regardless of contractions.”
Rationale: Rupture of membranes requires immediate medical attention, even if contractions have not started. The nurse should advise the client to go to the hospital immediately.
A client in labor calls the hospital reporting contractions 5 minutes apart, lasting 45 seconds, and they are able to carry on a conversation during contractions. How should the nurse respond?
A. “Stay home and monitor the contractions; come in when they are 4 minutes apart.”
B. “You are in active labor; come to the hospital immediately.”
C. “Stay at home until your contractions become stronger and last for one minute.”
D. “It’s too early for you to come to the hospital; wait until contractions are 2 minutes apart.”
C. “Stay at home until your contractions become stronger and last for one minute.”
Rationale: Contractions in early labor can be irregular and may not cause difficulty in talking. The client should stay home until contractions are stronger and last 60 seconds.
The nurse is assessing a postpartum client 12 hours after delivery. Which finding would the nurse document as normal?
A. The fundus is palpable 2 cm above the umbilicus.
B. The fundus is at the level of the umbilicus and firm.
C. The fundus is midway between the umbilicus and the pubic symphysis.
D. The fundus cannot be palpated in the abdomen.
B. The fundus is at the level of the umbilicus and firm.
Rationale: Within the first 12 hours postpartum, the fundus is typically at the level of the umbilicus and should be firm. A fundus above the umbilicus or not firm may indicate complications such as uterine atony or retained placental fragments.
Which of the following are normal findings during uterine involution? (SATA)
A. The uterus descends approximately 1 cm per day.
B. By 10 days postpartum, the uterus is no longer palpable.
C. The uterus shrinks by 50% within 3 days.
D. Lochia is present as the upper layer of the decidua sloughs off.
E. The fundus remains at the umbilicus for 7 days postpartum.
A. The uterus descends approximately 1 cm per day.
B. By 10 days postpartum, the uterus is no longer palpable.
D. Lochia is present as the upper layer of the decidua sloughs off.
Rationale: Uterine involution involves the uterus descending about 1 cm per day, becoming non-palpable by 10 days postpartum. Lochia occurs due to sloughing of the upper decidual layer. The uterus shrinks by 50% within 1 week, not 3 days, and the fundus should descend daily, not remain at the umbilicus for 7 days.
A nurse is palpating the fundus of a postpartum client on day 5. Where should the fundus normally be located?
A. At the umbilicus
B. 2 cm above the umbilicus
C. 5 cm below the umbilicus
D. Not palpable
C. 5 cm below the umbilicus
Rationale: The uterus descends approximately 1 cm per day postpartum. By day 5, the fundus should be about 5 cm (or 5 fingerbreadths) below the umbilicus, indicating normal uterine involution.
The nurse is assessing a postpartum client 3 days after delivery. The fundus is 2 cm above the umbilicus and soft. What is the nurse’s priority action?
A. Document the finding as normal uterine involution.
B. Encourage the client to breastfeed to stimulate uterine contractions.
C. Notify the healthcare provider of potential uterine atony.
D. Perform a fundal massage and reassess.
D. Perform a fundal massage and reassess.
Rationale: A soft, elevated fundus on day 3 postpartum is abnormal and may indicate uterine atony. The nurse should perform a fundal massage to promote uterine contractions and reassess. If the fundus remains soft, further interventions, such as notifying the healthcare provider, may be necessary.
Which process is primarily responsible for the shrinking of the uterus postpartum?
A. Regeneration of epithelial tissue
B. Sloughing of the decidua
C. Catabolism of uterine muscle cells
D. The release of estrogen and progesterone
C. Catabolism of uterine muscle cells
Rationale: Catabolism is the process by which muscle cells and fibers shrink, leading to the gradual reduction in uterine size postpartum. Regeneration of epithelial tissue and sloughing of the decidua contribute to lochia production, while hormonal changes support the overall process.
A postpartum client asks why she is experiencing lochia. Which explanation by the nurse is most appropriate?
A. “Lochia occurs because the uterus is healing after delivery.”
B. “It is a result of hormonal changes as you adjust to postpartum life.”
C. “Lochia is the shedding of the lower layers of the uterine lining.”
D. “It happens when uterine contractions are too strong.”
A. “Lochia occurs because the uterus is healing after delivery.”
Rationale: Lochia results from the sloughing of the upper layer of the decidua and the regeneration of the uterine epithelium as the uterus heals after delivery. It is a normal part of the postpartum period.
The nurse is reviewing uterine involution with a postpartum client. Which statements by the client indicate a correct understanding? (SATA)
A. “My uterus will shrink by half within the first week.”
B. “The fundus will descend about 1 cm each day.”
C. “My uterus will return to its normal size within 2 days after delivery.”
D. “By 10 days postpartum, my uterus will not be palpable in my abdomen.”
E. “Lochia is a sign that my uterus is not healing properly.”
A. “My uterus will shrink by half within the first week.”
B. “The fundus will descend about 1 cm each day.”
D. “By 10 days postpartum, my uterus will not be palpable in my abdomen.”
Rationale: The uterus shrinks by approximately 50% within the first week, descends about 1 cm per day, and is typically non-palpable by day 10. Lochia is a normal sign of healing, not an indicator of improper healing. It takes several weeks for the uterus to return to its normal size.
A postpartum client’s fundus is palpated two fingerbreadths above the umbilicus on day 3 postpartum. What is the nurse’s priority action?
A. Encourage ambulation to promote uterine descent.
B. Perform a fundal massage to ensure proper contraction.
C. Assist the client in emptying her bladder.
D. Document the finding as normal involution.
C. Assist the client in emptying her bladder.
Rationale: A full bladder can displace the uterus, inhibiting proper involution and increasing the risk of postpartum hemorrhage. Assisting the client to empty her bladder can promote uterine descent. Fundal massage is unnecessary unless the uterus is soft or boggy.
Which of the following factors is most likely to inhibit uterine involution?
A. Breastfeeding
B. A complication-free labor
C. Retained placental fragments
D. Early ambulation
C. Retained placental fragments
Rationale: Retained placental fragments interfere with uterine contraction and healing, leading to subinvolution. Breastfeeding and early ambulation promote uterine involution through stimulation of uterine contractions and improved circulation, while a complication-free labor minimizes uterine trauma.
Which factors facilitate normal uterine involution postpartum? (SATA)
A. Breastfeeding
B. Uterine infection
C. A full bladder
D. Complete expulsion of the placenta
E. Early ambulation
A. Breastfeeding
D. Complete expulsion of the placenta
E. Early ambulation
Rationale: Breastfeeding, complete expulsion of the placenta, and early ambulation facilitate uterine involution by promoting uterine contractions and ensuring the uterus remains empty and active. A full bladder and uterine infection inhibit involution.
The nurse is assessing a postpartum client on day 10. Which finding would indicate normal uterine involution?
A. The fundus is firm and palpable at the umbilicus.
B. The fundus is not palpable in the abdomen.
C. The fundus is two fingerbreadths above the umbilicus.
D. The fundus is midway between the umbilicus and the pubic symphysis.
B. The fundus is not palpable in the abdomen.
Rationale: By day 10 postpartum, the uterus has descended into the true pelvis and is no longer palpable in the abdomen, indicating normal involution. A fundus at or above the umbilicus at this stage is abnormal and suggests subinvolution.
