Question 1

A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 c m dilated. The nurse knows that the client is in which phase of labor?

Accepted Answer

The transition phase of labor is characterized by cervical dilation of 8 to 10 cm, 100 percent effacement, and contractions that are very close together, which matches the description given for the client.

Question 2

The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include?

Accepted Answer

True labor is confirmed by cervical changes, which is the most definitive way to differentiate it from false labor.

Question 3

The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A, B, C

Question 4

The 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?

Accepted Answer

The client's symptoms suggest she is experiencing "nesting" behavior (a burst of energy and an urge to clean or organize the home before labor begins), lightening (the baby dropping lower into the pelvis, relieving pressure on the diaphragm but increasing pressure on the bladder), and the start of irregular contractions. These are signs that labor may be starting soon.

Question 5

A client who is having false labor most likely would have which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

False labor, also known as Braxton Hicks contractions, is characterized by contractions that do not increase in intensity or frequency (A), do not lead to progressive cervical changes (C is therefore incorrect), often involve discomfort localized to the abdomen without radiating (D), and can often be alleviated or lessened with rest and warm baths (E). True labor contractions, on the other hand, increase in intensity and frequency (B is incorrect) and lead to cervical effacement and dilation (C is incorrect for false labor).

Question 6

The 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?

Accepted Answer

These symptoms are common signs that the baby's head has descended further into the pelvis, indicating progression towards labor. This descent can increase pressure on the bladder, leading to increased urinary frequency, and on the pelvis, causing increased pelvic pressure.

Question 7

A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following?

Accepted Answer

The client's symptoms indicate lightening, which occurs when the fetus descends into the pelvis, leading to easier breathing but potentially causing leg cramps, edema, and increased vaginal secretions due to the change in pressure and circulation.

Question 8

The charge nurse has received the shift change report. Which client requires immediate intervention?

Accepted Answer

The woman at 3 cm who is screaming in fear due to a traumatic past experience requires immediate intervention to address her emotional distress and ensure her safety and well-being during labor.

Question 9

The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor will most likely include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

False labor is characterized by contractions that do not intensify with activity and pain that is usually localized to the abdomen and does not radiate.

Question 10

The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond?

Accepted Answer

In normal labor, uterine contractions intensify in strength and also increase in duration, which helps to facilitate the dilation and effacement of the cervix, leading to the progression of labor.

Question 11

The client has asked the nurse why her cervix has only changed from 1 to 2 c m in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client?

Accepted Answer

The nurse's best response is to explain that cervical effacement, or thinning, is also a sign of labor progress, in addition to dilation. This helps the client understand that changes in the cervix are multifaceted and not limited to dilation alone.

Question 12

To identify the duration of a contraction, the nurse would do which of the following?

Accepted Answer

To identify the duration of a contraction, the correct method is to start timing from the beginning of one contraction to the completion of the same contraction. This measures how long a single contraction lasts.

Question 13

The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of The nurse is caring for laboring clients....

Question 14

A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 c m, 100% effaced, and -2 station. What best describes this labor?

Accepted Answer

The client is in the latent phase of labor, characterized by contractions that are relatively infrequent and irregular, mild to moderate in intensity, and result in slow cervical dilation and effacement. The cervix dilated to 2 cm and 100% effaced indicates early labor.

Question 15

A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

Android and Platypelloid pelvic shapes are considered least adequate for vaginal childbirth. The Android shape resembles a male pelvis, which is more narrow and not as well suited for childbirth. The Platypelloid shape is flat, making it difficult for the baby to navigate through the birth canal.

Question 16

Premonitory signs of labor include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of Premonitory signs of labor include which of...

Question 17

A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilation 6 c m; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues?

Accepted Answer

Cervical dilation of 6 cm typically indicates that the woman is in active labor, which usually involves stronger and more intense contractions than described as "mild." The contraction frequency and duration are more consistent with early labor, not the active phase suggested by the 6 cm dilation.

Question 18

How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part?

Accepted Answer

When the fetal shoulder is the presenting part, it indicates a transverse lie, which is a type of breech presentation. This means the baby is positioned horizontally in the uterus, making vaginal delivery difficult.

Question 19

Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first?

Accepted Answer

The sudden gush of blood and lengthening of the umbilical cord suggest placental separation, so the nurse should watch for the emergence of the placenta.

Question 20

A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor?

Accepted Answer

The transition phase of labor is characterized by contractions that are very close together (1-2 minutes apart) and last 60-90 seconds. It is the most intense phase of labor, often causing increased apprehension and irritability in the mother.

Quiz 19: Processes and Stages of Labor and Birth

The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include?

The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

The 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?

A client who is having false labor most likely would have which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

The 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?

The charge nurse has received the shift change report. Which client requires immediate intervention?

The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor will most likely include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected.