148 Questions
Which statement indicates the client is experiencing true labor contractions?
The contractions are regular and about 6 minutes apart
What does the term 'cervical effacement' refer to during labor?
The degree of thinning of the cervix
Which finding indicates that the placenta is separating during the third stage of labor?
The uterus becomes firm and globular in shape
During a cervical exam, what is the nurse assessing when evaluating cervical dilation?
The extent of opening to the widest diameter
What is a common premonitory sign that labor may be starting?
Expulsion of the mucous plug
During the third stage of labor, which event occurs after the placenta separates?
Expulsion of the placenta from the uterus
Which stage of labor starts after the newborn is born and ends with the separation and birth of the placenta?
Placental expulsion stage
If the fetus of a nulliparous woman is in a shoulder presentation, the nurse should prepare the client for which type of birth?
Cesarean
Which of the following assessment findings indicates the client is in the latent phase of the first stage of labor?
Cervical dilation of 3 cm, cervical effacement of 30%, and contractions every 7 to 8 minutes lasting about 40 seconds
Which pelvic shape is the most favorable for a vaginal birth?
Gynecoid
What is the most appropriate suggestion by the nurse when a woman reports her water just broke?
Come to the clinic or emergency department for an evaluation.
Which of the following is the most likely recommendation for a woman with a $5(7 + 3)$ cm cervical dilation, 50% effacement, and contractions every 4 minutes lasting 50 seconds?
Admission to the hospital for active labor management
A woman reports that she is experiencing a sudden urge to push. Which stage of labor is she most likely in?
Second stage of labor
Which of the following is the most common cause of a shoulder dystocia?
A narrow maternal pelvis
A nulliparous woman is in active labor with a cervical dilation of 6 cm and 70% effacement. Which of the following is the most appropriate nursing intervention?
Closely monitor the woman's progress and provide supportive care
A woman in labor reports feeling a sudden, intense pain in her lower abdomen. Which of the following is the most likely cause?
Uterine rupture
Which component is considered part of the true pelvis?
Pelvic inlet
What term would the nurse use to describe the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother?
Longitudinal
If the fetal position is documented as LSA, what part is the presenting part?
Buttocks
Which of the following movements would the nurse include when describing the typical movements of the fetus as it travels through the passageway?
Internal rotation
The nurse is monitoring a woman in labor and notes the time from the onset of a contraction to its highest intensity. What phase is the nurse interpreting?
Acme
Which of the following is considered part of the true pelvis?
Pelvic outlet
What term would the nurse use to describe the relationship between the long axis of the fetus and the long axis of the mother?
Longitudinal
If the fetal position is documented as LOA, what part is the presenting part?
Occiput
Which of the following movements would the nurse include when describing the typical movements of the fetus as it travels through the passageway?
Descent
The nurse is monitoring a woman in labor and notes the time from the onset of a contraction to its highest intensity. What phase is the nurse interpreting?
Acme
Which phase of a uterine contraction involves the relaxation of the uterine muscle fibers?
Decrement
Which finding would indicate a cause for concern during a contraction in a woman in labor?
Respiratory rate of 10 breaths/minute
Which of the following describes a woman in the latent phase of labor?
Contractions every 5 minutes, cervical dilation 3 cm
Which response by the nurse would be most appropriate when a pregnant woman asks, "How long do you think I will be in labor?"
"It's difficult to predict how your labor will progress, but we'll be there for you the entire time."
Which of the following is a common physiologic response during labor?
Increase in respiratory rate
What is the primary function of the decrement phase of a uterine contraction?
To relax the uterine muscle fibers after the contraction
Which of the following would be considered a cause for concern during a contraction in a woman in labor?
Decrease in respiratory rate from 14 breaths/minute to 8 breaths/minute
Which of the following is a characteristic of the latent phase of labor?
Contractions every 5 minutes, cervical dilation 3 cm
Which of the following factors can promote coping and a positive labor experience?
Participation in a pregnancy exercise program
What is the primary role of the bony pelvis during labor?
To provide a rigid passageway for the fetus
Which part of the maternal pelvis is the true pelvis associated with?
The pelvic outlet
In a frank breech presentation, what is the position of the fetal legs?
Extended upward toward the face
What is the most likely event that has occurred when a pregnant woman reports easier breathing but increased pelvic pressure and back pain?
Lightening
Which of the following statements about the maternal pelvis is true?
The true pelvis is the passageway for the fetus
In a full or complete breech presentation, what is the position of the fetal legs?
Crossed in a sitting position
What is the term used to describe the passage of the mucous plug that fills the cervical canal during pregnancy?
Bloody show
What is the primary function of Braxton Hicks contractions during pregnancy?
To prepare the cervix for labor
Which part of the maternal pelvis lies above the linea terminalis?
The false pelvis
In a footling breech presentation, what is the position of the fetal legs?
One or both legs presenting first
What does effacement refer to?
The degree of thinning of the cervix
What is the fetal presenting part determined by?
Vaginal examination
What symptom would indicate that a woman is likely in active labor?
Moderately strong contractions every 4 minutes, lasting about 1 minute
Which position is recommended to facilitate the progress of labor?
Upright position
What is a characteristic sign of the late active phase of the first stage of labor?
Frequent contractions about every 1-2 minutes and increased irritability
What is indicated by a cervical dilation of 8 cm and 90% effacement?
Late active phase of the first stage of labor
What is the significance of bloody show during labor?
It is a premonitory sign of labor
What is a characteristic of the latent phase of the first stage of labor?
Cervical dilation of 0-3 cm and effacement of 0-40%
What is the perineal phase of the second stage of labor characterized by?
Active pushing and bearing down
What is the significance of the upright position during labor?
It reduces the length of labor and improves fetal positioning
Which phase of labor is characterized by progressive cervical dilation?
First stage
What is the primary change during the second stage of labor?
Fetal movement through the birth canal
In the active phase of labor, how often do contractions typically occur?
Every 90 seconds
What percentage of cervical effacement suggests the latent phase of labor?
30%
Which of the following is a common sign that labor may be approaching?
Sudden burst of energy
What hormone is thought to be responsible for the burst of energy before labor?
Epinephrine
What is a common activity women engage in before labor known as nesting?
Cleaning the house
What may increased energy levels before labor be attributed to?
Decrease in progesterone levels
What is the most appropriate way for a nurse to estimate the length of a woman's first labor?
Explain that labor length cannot be accurately predicted
Which fetal skull feature is most important for allowing the head to move through the birth canal?
Sutures allowing overlapping of cranial bones
If the fetal presenting part is at the level of the maternal ischial spines, what station is documented?
0 station
During the first stage of labor, what is the major change the nurse should describe to the patient?
Gradual cervical dilation
What is the most important role of the uterine contractions during labor?
Gradually dilate the cervix and propel the fetus
What cranial bone overlaps the smallest at the posterior fontanelle?
Occipital bone
Which stage of labor involves the birth of the placenta?
Third stage
At what cervical dilation is a woman considered to be in the second stage of labor?
10 cm
What is the maximum duration typically allowed for the second stage in a nulliparous woman?
2 hours
Which factor has the greatest influence on the duration of labor?
Parity (number of previous births)
Which stage of labor starts after the newborn is born and ends with the separation and birth of the placenta?
Third stage
If a client's pelvic shape is identified as the most favorable one for a vaginal birth, which type of pelvic shape would the nurse have noted?
Gynecoid
If a woman's water just broke, which suggestion by the nurse would be most appropriate?
Come to the clinic or emergency department for an evaluation.
A client is admitted to the labor and birthing suite in early labor. If the nurse determines that the client's pelvic shape is the most favorable one for a vaginal birth, which pelvic shape would the nurse have noted?
Gynecoid
A woman in labor is assessed to have a cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in which stage of labor?
Latent phase of the first stage
A fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth?
Cesarean
A client is admitted to the labor and birthing suite in early labor. The nurse determines that the client's pelvic shape is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted?
Gynecoid
A woman reports that her water just broke. Which suggestion by the nurse would be most appropriate?
Come to the clinic or emergency department for an evaluation.
A woman is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted?
Gynecoid
A client's water just broke. Which suggestion by the nurse would be most appropriate?
Come to the clinic or emergency department for an evaluation.
Which statement by the client would most likely indicate that she is experiencing true labor contractions?
The contractions are regular, increasing in intensity and duration, and she cannot talk through them.
During a cervical exam, what is the nurse assessing when evaluating cervical effacement?
The degree to which the cervix has thinned out and incorporated into the lower uterine segment.
When assessing for signs that the placenta is separating during the third stage of labor, which finding would be most indicative?
The uterus becomes globular and rises upward.
Which of the following statements regarding the maternal pelvis is true?
The gynecoid pelvic shape is considered the most favorable for vaginal birth.
Which of the following fetal movements would the nurse expect to observe as the fetus descends through the birth canal?
Engagement, descent, flexion, internal rotation, extension, restitution
A nulliparous woman in active labor reports a sudden, intense urge to bear down and push. Which stage of labor is she most likely experiencing?
Early second stage of labor
Which of the following is a sign that the client is in the late active phase of the first stage of labor?
Frequent contractions about every 1 to 2 minutes, the client becoming irritable and no longer allowing the nurse to palpate the fundus during contractions, and cervical dilation of 8 cm and 90% effacement.
What is the primary role of the bony pelvis during labor?
To guide the fetus through the birth canal and facilitate delivery.
A woman in labor reports a sudden urge to push. Which stage of labor is she most likely in?
Second stage of labor
Which of the following is the most likely recommendation for a woman with a $5(7 + 3)$ cm cervical dilation, 50% effacement, and contractions every 4 minutes lasting 50 seconds?
Proceed to the hospital for active labor management.
What is the most appropriate way for a nurse to estimate the length of a woman's first labor?
Monitor the progress of labor through regular cervical examinations.
Which of the following is the most common cause of a shoulder dystocia?
Fetal macrosomia (large baby)
What is the primary function of Braxton Hicks contractions during pregnancy?
To prepare the uterus for the work of labor.
Which pelvic shape is the most favorable for a vaginal birth?
Gynecoid pelvis
What is the significance of bloody show during labor?
It is a premonitory sign of the onset of labor.
What is the maximum duration typically allowed for the second stage in a nulliparous woman?
2 hours
Which factor is considered the most important in allowing the fetal head to move through the birth canal?
Sutures
When the presenting part of the fetus is at the level of the maternal ischial spines, what is the documented station?
0
Which of the following is the major change that occurs during the first stage of labor?
Cervical dilation (dilatation)
During the third stage of labor, which event occurs after the placenta separates?
Delivery of the fetal membranes
Which pelvic shape is considered the most favorable for a vaginal birth?
Gynecoid
What is the maximum duration typically allowed for the second stage of labor in a nulliparous woman?
2 hours
Which of the following is a characteristic of the latent phase of labor?
Cervical dilation of 4 cm and 50% effacement
Which of the following is the most common cause of a shoulder dystocia?
Fetal macrosomia
What is the significance of bloody show during labor?
Indicates the active phase of labor has begun
Which of the following is a common physiologic response during labor?
Increased temperature
In a complete or full breech presentation, how are the fetal legs positioned?
Crossed in a seated position above the cervix
Which of the following statements accurately describes the relationship between the maternal bony pelvis and the birth process?
The bony pelvis is relatively unyielding and is the primary passageway for the fetus.
A woman in her third trimester reports increased pelvic pressure, cramping, and lower back pain, along with easier breathing. Which event is most likely occurring?
Lightening (fetal descent)
In a frank breech presentation, what is the position of the fetal legs?
Extended upward toward the fetal face
Which part of the maternal pelvis lies above the imaginary linea terminalis?
False pelvis
If a fetus is documented as having a LOA (Left Occipito-Anterior) position, what part is the presenting part?
Occiput (back of the head)
During the second stage of labor, what is the primary change occurring?
Descent of the fetus through the birth canal
What is the term used to describe the passage of the mucous plug that fills the cervical canal during pregnancy?
Bloody show
During the first stage of labor, what is the major change the nurse should describe to the patient?
Thinning and opening of the cervix
What is the term used to describe the relationship between the long axis (spine) of the fetus and the long axis (spine) of the mother?
Lie
Which fetal skull diameter is considered the most important in affecting the birth process?
Biparietal
A nurse is providing care to a woman in the active phase of labor. Which of the following would be the MOST concerning finding during a contraction?
Fetal heart rate decelerations
A woman reports a sudden increase in energy and a strong urge to clean and organize her home prior to the onset of labor. What is the MOST likely explanation for this behavior?
The woman is experiencing a surge of adrenaline (epinephrine)
A nurse is caring for a woman in the first stage of labor. Which of the following findings would MOST likely indicate the active phase of labor?
Cervical dilation of 6 cm and 80% effacement
A nulliparous woman is in active labor with a cervical dilation of 6 cm and 70% effacement. Which of the following is the MOST appropriate nursing intervention?
Encourage ambulation and position changes
A nurse is caring for a woman in the second stage of labor. Which of the following is the PRIMARY change that occurs during this stage?
Fetal movement through the birth canal
A nurse is caring for a woman in labor and notes that the time from the onset of a contraction to its highest intensity is 45-60 seconds. What phase of labor is the nurse interpreting?
Active phase
A nulliparous woman is in labor with a fetal presentation of shoulder dystocia. What is the MOST appropriate nursing intervention?
Perform maneuvers to facilitate delivery of the shoulders
A woman in labor reports a sudden urge to push. Which stage of labor is she MOST likely in?
Second stage
What is the significance of the acronym 'LSA' when documenting fetal position?
L denotes longitudinal lie, S denotes sacrum (buttocks) as the presenting part, A denotes anterior position
During the true labor process, which of the following is NOT one of the cardinal movements the fetus undergoes as it passes through the birth canal?
Abduction
When assessing uterine contractions during labor, which phase does the time from onset to peak intensity represent?
Increment
What is the definition of 'fetal lie' in relation to the birthing process?
The relationship between the long axis of the fetus and the long axis of the mother
Which part of the maternal pelvis provides the most obstruction and resistance during labor?
Pelvic outlet
At what cervical dilation is a nulliparous woman typically considered to have entered the active phase of the first stage of labor?
5-6 cm
Which of the following is the most accurate interpretation of $80%$ cervical effacement?
The cervix has thinned out and shortened by 80%
Which of the following fetal skull features is most advantageous for allowing molding and passage through the birth canal?
Flexible cranial bones with overlapping sutures
A woman in active labor is contracting every 2-3 minutes. What is the most appropriate initial nursing intervention?
Assess fetal heart rate patterns
Which of the following pelvis types is considered most favorable for vaginal birth?
Gynecoid pelvis
During the decrement phase of a uterine contraction, what occurs?
The uterine muscle fibers relax
Which factor is least likely to promote coping and a positive labor experience?
High anxiety level
In the active phase of labor, how frequently do contractions typically occur?
Every 2-3 minutes
What is the significance of bloody show during labor?
It indicates the cervix is dilating and effacing
Which of the following movements would the nurse include when describing the typical movements of the fetus as it travels through the passageway?
Engagement, descent, flexion, internal rotation, extension, restitution, external rotation
What is the primary function of Braxton Hicks contractions during pregnancy?
To prepare the uterus for true labor contractions
Which of the following is a characteristic of the latent phase of the first stage of labor?
Contractions occurring every 5-20 minutes
What is the most appropriate way for a nurse to estimate the length of a woman's first labor?
Based on the woman's parity
Which of the following is considered part of the true pelvis?
Symphysis pubis
What is the most likely event that has occurred when a pregnant woman reports easier breathing but increased pelvic pressure and back pain?
The fetus has engaged in the pelvis
Test your knowledge on distinguishing false labor from true labor in pregnant women. Identify key statements by clients that may indicate false labor based on symptoms and experiences.
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