Deck 16: Processes and Stages of Labor and Birth

Question 1

The nurse suspects that a pregnant client is experiencing true labor. What did the nurse assess to make this clinical determination? Select all that apply.
1) Contractions increase in intensity.
2) Discomfort occurs in the abdomen.
3) Contractions occur at regular intervals.
4) Walking has no effect on the contractions.
5) Time between contractions gradually becomes shorter.

Answer 1

1, 3, 5

Question 2

A client entering the third trimester of labor is concerned about having enough muscle strength and stamina to give birth. Which exercises should the nurse review with the client to facilitate the birthing process? Select all that apply.
1) Yoga
2) Pelvic tilt
3) Pelvic rock
4) Kegel exercises
5) McRoberts exercises

Answer 2

2, 3, 4, 5

Question 3

A pregnant client expresses a desire to use the Lamaze method for the upcoming birth of her child. What should the nurse explain as elements of this birthing process? Select all that apply.
1) Guided imagery
2) Sensory memory
3) Dissociative relaxation
4) Controlled muscle relaxation
5) Differentiated breathing patterns

Answer 3

3, 4, 5

Question 4

During the fourth stage of labor, the client's blood pressure (BP) is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What should the nurse do?
1) Massage the fundus.
2) Continue to monitor.
3) Turn the client onto her left side.
4) Place the bed in Trendelenburg position.

Question 5

A healthy 18-year-old client who is at 40 weeks' gestation experiences vaginal expulsion of stringy mucus followed by blood-tinged secretions unaccompanied by discomfort or any other changes. Based upon these findings, what is most likely to occur within the next 24 to 48 hours?
1) Onset of labor
2) Cesarean section
3) Chorioamnionitis
4) Spontaneous abortion

Question 6

The spouse is concerned that the client in labor will be hungry since the last time any food was eaten was several hours ago. What should the nurse explain as effects of the labor process on the client's gastrointestinal system? Select all that apply.
1) Reduced gastric motility
2) Increased gastric volume
3) Increased gastric motility
4) Reduced absorption of food
5) Prolonged gastric emptying time

Question 7

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which pain response should the nurse identify as most likely to impede progress in labor?
1) Muscle tension
2) Increased pulse
3) Increased respirations
4) Elevated blood pressure

Question 8

While caring for a client in labor the nurse determines that the baby's head has internally rotated. The client's spouse asks about other positional changes that will occur during the labor and birth. How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation?
1) Expulsion, external rotation, and restitution
2) Restitution, flexion, external rotation, and expulsion
3) Extension, restitution, external rotation, and expulsion
4) Flexion, extension, restitution, external rotation, and expulsion

Question 9

The primiparous client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. How should the nurse respond to this client?
1) "What did you expect? You have only had contractions for a few hours. Labor takes time."
2) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now."
3) "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."
4) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

Question 10

Which client requires immediate intervention by the labor and delivery nurse?
1) Primipara in active labor with urine output of 100 mL/hour
2) Primipara that delivered 1 hour ago with white blood cells (WBCs) of 50,000
3) Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg
4) Multipara at 5 cm with a respiratory rate of 22 between contractions

Question 11

The nurse is reviewing the different types of fetal presentations with a client nearing the end of her pregnancy. Which presentation should the nurse identify as being ideal?

Question 12

A client is entering the end of the second stage of labor. What should the nurse expect to assess in this client? Select all that apply.
1) Bulging perineum
2) Parting of the labia
3) Crowning of the fetus
4) Increasing bloody show
5) Increasing rectal pressure

Question 13

A client in the beginning stages of labor asks the nurse if the labor process will hurt the baby. What should the nurse explain to the client about the fetus's response to labor? Select all that apply.
1) The baby's heart rate will change.
2) The baby feels no pain or sensations.
3) The baby is sensitive to light and sounds.
4) The baby's oxygen level drops about 10%.
5) The blood pressure protects the baby during labor.

Question 14

A client whose cervix is dilated 8 cm is restless and frequently changing position in an attempt to get comfortable. Which nursing action is most important?
1) Leave the client alone so she can rest.
2) Ask the family to take a coffee and snack break.
3) Reassure the client that she will not be left alone.
4) Encourage the client to have an epidural for pain.

Question 15

A client in labor with cervical dilation of 9 cm is experiencing contractions every 2 minutes that are 60 to 90 seconds in duration and is complaining of excruciating rectal pressure. How should the nurse interpret this complaint?
1) The client's complaint is congruent with her current stage of labor.
2) The client's complaint may indicate the need for delivery via cesarean section.
3) Based upon the client's complaint, she is experiencing the active phase of labor.
4) The client's complaint is consistent with placental separation, which is normal for her current stage of labor.

Question 16

The primiparous client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make?
1) "You should not work so much at this point in pregnancy."
2) "Your body may be telling you it is going into labor soon."
3) "If the bladder pressure continues, come in to the clinic tomorrow."
4) "What you are describing is not commonly experienced in the last weeks."

Question 17

The primiparous client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?
1) "Come in for an appointment today and we will check everything out."
2) "Unless you have pain with urination, we do not need to worry about it."
3) "This might indicate that the baby is no longer in a head down position."
4) "These symptoms usually mean the baby's head has descended further."

Question 18

A 25-year-old woman who is at 38 weeks' gestation with her first pregnancy is embarrassed because of going to the hospital 3 times in the last week for false labor. How should the nurse respond?
1) "Do not feel bad. Everyone makes mistakes sometimes."
2) "It is impossible to distinguish between false labor and true labor."
3) "We will discuss the differences between true labor and false labor so this does not happen again."
4) "It is very difficult to tell the difference between true and false labor. Please know we are here to take care of you whenever you need us."

Question 19

The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply.
1) Multipara at 3 cm, fetus in longitudinal lie
2) Primipara at 7 cm, fetus in military attitude
3) Multipara at 6 cm, fetus at −2 station, mild contractions
4) Primipara at 5 cm, fetal presenting part is right shoulder
5) Primipara at 4 cm, fetus with macrocephaly due to hydrocephalus

Question 20

The nurse is teaching a prenatal class. What characteristics about false labor should the nurse include? Select all that apply.
1) Increased thin vaginal secretions
2) Pain in the abdomen that does not radiate
3) Progressive cervical effacement and dilatation
4) Contractions that do not intensify while walking
5) An increase in the intensity and frequency of contractions