FIRST STAGE OF LABOR SHERPATH EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 FIRST STAGE OF LABOR SHERPATH EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ What approach would a nurse take to best assess the progress of a woman in labor? Correct Answer: Observe for classic signs of labor progress while keeping in mind that labor is variable from birth to birth. It is appropriate to monitor for classic signs while recognizing that not every labor demonstrates these signs. Which signs and symptoms exhibited by the woman in labor suggest that she may be getting closer to delivery? Correct Answer: - Contractions are strong upon palpation. - Contractions are every 1 to 2.5 minutes. - There is a large amount of bloody mucus on the pad. A woman is considered to be in active labor when the cervix is at least _____ cm dilated. Correct Answer: 6 2 Active labor generally begins at 6 cm dilation. Which assessment would the nurse complete when a woman is in active labor? Correct Answer: Fetal heart rate and pattern every 15 to 30 minutes This is appropriate in active labor. Match the laboring positions to their advantages. Correct Answer: Prevents supine hypotension, promotes placental blood flow - Side-lying Allows for rocking, bouncing, opening hips with contractions - Birthing ball Gravity promotes fetal descent, woman can walk - Standing Support person can reach back for massage, relieves back labor pain - Hands and knees Which signs are considered warning signs in labor that should be reported to the health care provider? Correct Answer: - The presence of thin green fluid leaking from the vagina - Maternal temperature of 100.8°F - Bright red vaginal bleeding with blood clots 3 - Minimal variability on the fetal heart tracing for the past 60 minutes A patient is experiencing painful contractions and is 7 cm dilated. The nurse recognizes these relevant cues and selects a hypothesis that the patient is in which phase of the first stage of labor? Correct Answer: Active labor Active labor typically begins at 6 cm, and most patients experience very frequent, painful contractions during this time. When caring for a patient in the active stage of labor, which solutions would the nurse generate to promote, protect, and support natural labor and birth? Correct Answer: - Encourage upright positions without restricting movement. - Provide support and allow visitors for labor support beginning in early labor. - Allow intermittent fetal monitoring, when appropriate, according to policy. Which nonpharmacologic actions can the nurse take that would be most beneficial to a patient in labor who expresses fear about movement in labor? Correct Answer: - Encourage support people to assist the patient with positioning. - Utilize positive and supportive language. - Provide options for new positioning. - Offer music, therapeutic breathing, or other distractions to help the patient cope. 4 A G2/P1 woman presents for evaluation. She is excited, can talk through regular contractions every 7 to 10 minutes, and states that her pain is "manageable." She does not desire epidural anesthesia in labor. The nurse suspects this patient is in which phase of labor? Correct Answer: Early labor In early labor a woman may present for evaluation as excited and able to talk and walk through most contractions, though they are still uncomfortable. She may be focused on herself and her baby. She may follow directions well and pain may be easily managed. The nurse receives reports on two women in early labor, a nulliparous woman and a multiparous woman. Both are 3 cm dilated. Which statement is true regarding who will enter active labor first? Correct Answer: They will both progress at similar rates. Nulliparous and multiparous women have been found to progress at similar rates in this phase. Which assessment findings in the laboring patient would suggest to the nurse that delivery is imminent? Correct Answer: - Contractions are 1.5 to 2 minutes apart. - Mucous vaginal discharge is bloody. - The woman is experiencing vomiting, nausea, and sweating. 5 - The patient complains of rectal pressure. A patient is experiencing intense back pain and discomfort during active labor. Which position would the nurse encourage the patient to assume? Correct Answer: Hands and knees A hands-and-knees position reduces back pain because the fetus falls forward, away from the sacral promontory. It promotes normal mechanisms of birth. The woman can use pelvic rocking to decrease back pain. Caregivers can rub the woman's back or apply sacral pressure easily. A woman is experiencing strong contractions every 1.5 to 2 minutes, feels rectal pressure, and has a large amount of bloody show. At which frequency would the nurse anticipate assessing the fetal heart rate and pattern? Correct Answer: Every 15 to 30 minutes Based on the patient's signs and symptoms, she is in active labor, so it is recommended that the nurse assess the fetal heart rate and pattern every 15 to 30 minutes. After assessment of an actively laboring woman, the nurse finds a fetal heart rate (FHR) of 180 beats/min with contractions occurring less than 2 minutes apart and lasting more than 90 seconds. Which action would the nurse take next? Correct Answer: Reposition the patient to her side and alert the health care provider. 6 The patient is experiencing tachysystole, fetal tachycardia, and incomplete uterine relaxation, which can lead to fetal compromise. Lateral positioning allows for optimal placental perfusion. The health care provider will need to evaluate this patient at the bedside. A patient in labor experiences minimal relief after nonpharmacologic interventions, and she is not coping well in labor. Which action would the nurse take next? Correct Answer: Educate on the risks and benefits of pharmacologic interventions. By providing the patient with education and options, the nurse empowers her to make decisions about her body and labor and delivery experience. Which solution can the nurse consider to encourage a positive birth experience for the patient and her support person following delivery? Correct Answer: Encourage the family to talk about the labor and delivery experience. Encouraging the patient and the support person to talk freely about the birth experience is a very important way to help them make sense of the experience and to reflect on the positive and negative aspects of the labor and delivery. List relevant patient cues in the order the nurse recognizes them in a primipara during labor as the patient progresses from the first stage of labor to the second stage of labor. 7 Correct Answer: - Patient wakes up and feels mild contractions at home. - Cervix is thick and 50% effaced on assessment at the hospital. - Cervix is 6 cm dilated. - Contractions become closer and coordinated. - Patient has bloody show and reports rectal pressure.