Test Bank Lowdermilk: Maternity & Women’s Health Care Chapter 16: Labor and Birth Processes ,100% CORRECT

Test Bank Lowdermilk: Maternity & Women’s Health Care Chapter 16: Labor and Birth Processes MULTIPLE CHOICE 1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. The nurse’s answer is based on the knowledge that the anterior fontanel closes after birth by: a. 2 months b. 8 months c. 12 months d. 18 months ANS: D The larger of the two fontanels, the anterior fontanel closes by 18 months after birth. The posterior fontanel closes at 6 to 8 weeks. Eight months is much too early for the anterior fontanel to close. It closes by 18 months after birth. Twelve months is too soon. The anterior fontanel closes by 18 months. DIF: Cognitive Level: Knowledge REF: 370 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 2. When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: a. Lie b. Presentation c. Attitude d. Position ANS: C Attitude is the relation of the fetal body parts to each other. Lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relation of the presenting part to the four quadrants of the mother’s pelvis. DIF: Cognitive Level: Knowledge REF: 370 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 3. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother’s right side close to midline. What is the likely position of the fetus? a. ROA b. LSP c. RSA d. LOA ANS: C Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother’s right side denotes the location of the presenting part in the mother’s pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is positioned anteriorly in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is positioned posteriorly in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be positioned anteriorly in the left side of the pelvis with the occiput as the presenting part. DIF: Cognitive Level: Comprehension REF: 371 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 4. What position is least effective when gravity is desired to assist in fetal descent? a. Lithotomy b. Kneeling c. Sitting d. Walking ANS: A The predominant position in the United States for physician- attended births is the lithotomy position, which requires a woman to be in a reclined position with her legs in stirrups. Gravity has little effect in this position. Kneeling helps align the fetus within the pelvic outlet and allows gravity to assist in fetal descent. Sitting helps align the fetus within the pelvic outlet and allows gravity to assist in fetal descent. Walking helps align the fetus within the pelvic outlet and allows gravity to assist in fetal descent. DIF: Cognitive Level: Analysis REF: 378 OBJ: Client Needs: Health Promotion and Maintenance TOP: “Nursing Process: Planning, Implementation” 5. The nurse recognizes that a woman is in true labor when she states: a. “I passed some thick, pink mucus when I urinated this morning.” b. “My bag of waters just broke.” c. “The contractions in my uterus are getting stronger and closer togeth d. “My baby dropped, and I have to urinate more frequently now.” ANS: C Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor. DIF: Cognitive Level: Application REF: 379 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 6. The nurse has received a report about a woman in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. The nurse’s interpretation of this assessment is that: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part i a. b. c. d. ANS: B above the ischial spines The cervix is 3 cm dilated, it is effaced 30%, and the presenting part i above the ischial spines The cervix is effaced 3 cm, it is dilated 30%, and the presenting part i below the ischial spines The cervix is dilated 3 cm, it is effaced 30%, and the presenting part i below the ischial spines The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. This cervix is dilated 3 cm and is 30% effaced. The presenting part is correct at 2 cm above the ischial spines. The cervix in this scenario is dilated 3 cm, is 30% effaced, and the presenting part is 2 cm below the ischial spines. All of these are incorrect interpretations of this vaginal examination. The dilation and effacement are correct at 3 cm and 30%; however, the presenting part is actually 2 cm above the ischial spines. DIF: Cognitive Level: Knowledge REF: “373, 376, 377” OBJ: Client Needs: Health Promotion and Maintenance TOP: “Nursing Process: Assessment, Planning” 7. A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate “labor is getting closer to starting.” The nurse informs the woman that which of the following is a sign that labor may begin soon? a. Weight gain of 1.5 to 2 kg (3 to 4 lb) b. Increase in fundal height c. Urinary retention d. Surge of energy ANS: D Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, the result of water loss caused by electrolyte shifts, which in turn are caused by changes in the estrogen and progesterone levels. When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor. DIF: Cognitive Level: Comprehension REF: 379 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 8. To adequately care for a laboring woman, the nurse should know which stage of labor varies the most in length? a. First b. Second c. Third d. Fourth ANS: A The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta. DIF: Cognitive Level: Knowledge REF: 380 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 9. The nurse expects which maternal cardiovascular finding during labor? a. Increased cardiac output b. Decreased pulse rate c. Decreased white blood cell (WBC) count d. Decreased blood pressure ANS: A During each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 10% to 15% in the first stage of labor and by about 30% to 50% in the second stage. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by about 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg. DIF: Cognitive Level: Comprehension REF: 383 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis 10. The factors that affect the process of labor and birth, known commonly as the five Ps, include all except: a. Passenger b. Passageway c. Powers d. Pressure ANS: D The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. Pressure is not one of the five Ps. The passenger (fetus and placenta) is one of the five Ps. The passageway (birth canal) is also one of the five Ps. Powers (contractions) are a necessary component of the five Ps. DIF: Cognitive Level: Knowledge REF: 369 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 11. To provide the necessary assessment of parent education, the nurse must know which bone is not a bone in the fetal skull? a. Parietal b. Temporal c. Fontanel d. Occipital ANS: C The fetal skull has two parietal bones, two temporal bones, an occipital bone, and a frontal bone. The fontanels are membrane-filled spaces. The fetal skull has two parietal bones. The fetal skull has two temporal bones. The fetal skull has an occipital bone and a frontal bone. DIF: Cognitive Level: Knowledge REF: 369 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 12. The slight overlapping of cranial bones or shaping of the fetal head during labor is called: a. Lightening b. Molding c. Ferguson reflex d. Valsalva maneuver ANS: B Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mother’s sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor. DIF: Cognitive Level: Knowledge REF: 370 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 13. Which presentation is described accurately in terms of both presenting part and frequency of occurrence? a. Cephalic: occiput; at least 96% b. Breech: sacrum; 10% to 15% c. Shoulder: scapula; 10% to 15% d. Cephalic: cranial; 80% to 85% ANS: A In cephalic presentations (head first) the presenting part is the occiput; this occurs in 96% of births. In a breech birth the sacrum emerges first; this occurs in about 3% of births. In shoulder presentations the scapula emerges first; this occurs in only 1% of births. In a cephalic presentation the part of the head or cranium that emerges first is the occiput; cephalic presentations occur in 96% of births. DIF: Cognitive Level: Comprehension REF: 370 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis 14. Regarding how the fetus moves through the birth canal, nurses should be aware that: a. The fetal attitude describes the angle at which the fetus exits the uter Of the two primary fetal lies, the horizontal lie is that in which the lon b. the fetus is parallel to the long axis of the mother c. The normal attitude of the fetus is called general flexion d. The transverse lie is preferred for vaginal birth ANS: C The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal body parts to each other. The normal attitude is called general flexion. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie, the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie. DIF: Cognitive Level: Comprehension REF: 370 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 15. A woman’s position is very important in the progress of labor. While discussing optimal positioning, maternity nurses should be able to tell the client that: a. The supine position commonly used in the United States increases blo b. The “all fours” position, on her hands and knees, is hard on her back c. Frequent changes in position help relieve her fatigue and increase her d. In a sitting or squatting position her abdominal muscles will have to w ANS: C Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The “all fours” position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions. DIF: Cognitive Level: Comprehension REF: 378 OBJ: Client Needs: Health Promotion and Maintenance TOP: “Nursing Process: Planning, Implementation” 16. Certain changes stimulate chemoreceptors in the aorta and carotid bodies to prepare the fetus for initiating respirations immediately after birth. These changes occur naturally during labor and include all except: a. Fetal lung fluid is cleared from the air passages during labor and vagi b. Fetal oxygen pressure decreases (PO2) c. Fetal arterial carbon dioxide increases (PCO2) d. Fetal respiratory movements increase during labor ANS: D Fetal respiratory movements actually decrease during labor. Fetal lung fluid is cleared from the air passages during labor and vaginal birth. Fetal oxygen pressure decreases (PO2). Fetal arterial carbon dioxide increases (PCO2). DIF: Cognitive Level: Comprehension REF: 383 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 17. Which description of the four stages of labor is correct for both definition and duration? First stage: onset of regular uterine contractions to full dilation; less th a. to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 t Third stage: active pushing to birth; 20 minutes (multiparous women) c. minutes (first-timer) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 ho ANS: A Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours). DIF: Cognitive Level: Comprehension REF: 380 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis 18. With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that: a. The seven critical movements must progress in a more or less orderly b. Asynclitism sometimes is achieved by means of the Leopold maneuve The effects of the forces determining descent are modified by the sha c. d. ANS: C woman’s pelvis and the size of the fetal head At birth the baby is said to achieve “restitution”; that is, a return to th of the womb The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the baby’s head; the Leopold maneuver is a means of judging descent by palpating the mother’s abdomen. Restitution is the rotation of the baby’s head after the infant is born. DIF: Cognitive Level: Comprehension REF: “369, 373” OBJ: Client Needs: Health Promotion and Maintenance TOP: “Nursing Process: Planning, Implementation” MULTIPLE RESPONSE 1. Signs that precede labor include (choose all that apply): a. Lightening b. Exhaustion c. Bloody show d. Rupture of membranes e. Decreased fetal movement ANS: A, C, D Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor. DIF: Cognitive Level: Comprehension REF: “378, 379” OBJ: Client Needs: Health Promotion and Maintenance TOP: “Nursing Process: Planning, Implementation” 2. Which factors influence cervical dilation? Choose all that apply. a. Strong uterine contractions b. The force of the presenting fetal part against the cervix c. The size of the female d. The pressure applied by the amniotic sac e. Scarring of the cervix ANS: A, B, D, E Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size does not affect cervical dilation. DIF: Cognitive Level: Comprehension REF: 381 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning COMPLETION 1. Which pelvic shape is ideal for a vaginal birth? ANS: Gynecoid The gynecoid pelvis is the most common; major gynecoid pelvic features are present in 50% of all women. Anthropoid and android features are less common, and platypelloid pelvic features are the least common. DIF: Cognitive Level: Comprehension REF: 374 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment TRUE/FALSE 1. The woman in labor should be encouraged to use the Valsalva maneuver (holding one’s breath and tightening abdominal muscles) for pushing during the second stage. Is this statement true or false? ANS: F The woman should actually be discouraged from using the Valsalva maneuver. This activity increases intrathoracic pressure, reduces venous return, and increases venous pressure. During the Valsalva maneuver fetal hypoxia may occur. The process is reversed when the woman takes a breath. DIF: Cognitive Level: Application REF: 378 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation