TEST BANK FOR MATERNAL NEWBORN NURSING THE CRITICAL COMPONENTS OF NURSING CARE 4TH EDITION CHAPTER 1-19 COMPLETE GUIDE A+ Study A nurse is caring for a patient who is in the active phase of the first stage of labor. How often should the nurse monitor fe

A nurse is caring for a patient who is in the active phase of the first stage of labor. How often should the nurse monitor fetal heart rate and contractions during this phase? 1. Every 5 to 10 minutes 2. Every 15 to 20 minutes 3. Every 30 to 40 minutes 4. Every 45 to 60 minutes 2. Every 15 to 20 minutes The nurse should monitor fetal heart rate and contractions every 15 to 20 minutes in the active phase of the first stage of labor. A woman in labor is dilated 9 cm, effaced 100%, and has contractions that occur almost every minute and last 90 seconds. She is exhausted and has trouble concentrating. The nurse recognizes that this woman is in which phase of the first stage of labor? 1. Latent phase 2. Active phase 3. Transitional phase 4. Expulsive phase 2. Active phase The latent phase is the early and slower part of labor with an average length of 9 hours for primiparous and 5 hours for multiparous women. Women in this phase are talkative and able to relax with the contractions. Characteristics of this phase are cervical dilation from 0 to 3 cm with effacement from 0% to 40%, along with contractions occurring every 5 to 10 minutes, lasting 30 to 45 seconds, and being of mild intensity. Women often describe these contractions as feeling like strong menstrual cramps. The active phase is characterized by cervical dilation of 4 to 7 cm with effacement of 40% to 80%. Contractions become more intense, occurring every 2 to 5 minutes with a duration of 45 to 60 seconds. The woman tends to be more serious and fatigued in this phase and turns inward. The transition phase is characterized by cervical dilation of 8 to 10 cm with complete (100%) effacement. Contractions are intense, occur every 1 to 2 minutes, and last 60 to 90 seconds. It is the shortest but most difficult phase of the first stage of labor, and the woman is typically exhausted and has trouble concentrating. Expulsive refers to the second stage of labor, not a phase of the first. It involves the delivery of the baby. Early in labor, a patient tells the nurse that she had an awful experience with pain in her last pregnancy and would like strongest pain relief option available for a vaginal birth. Which of the following should the nurse suggest to the patient? 1. Parenteral opioids 2. Nitrous oxide 3. Epidural anesthesia 4. General anesthesia 3. Epidural anesthesia Parenteral opioids blunt but do not eliminate pain, and therefore are not the strongest form of pain relief in labor and delivery. Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered by the laboring woman using a mouth tube or face mask, when she determines that she needs it. As an analgesic, it relieves pain, but does not block it as effectively as an epidural. Epidural anesthesia involves placement of a very small catheter and injection of local anesthesia and/or analgesia between the fourth and fifth vertebrae into the epidural space. It has the potential of 100% blockage of pain. General anesthesia is not typically used in vaginal births. 4.Early in labor, a patient tells the nurse that she would like an unmedicated birth, in general, but would like some pain relief that is fast-acting, that she can administer hersef, and that will not interfere with the normal physiology and progress of labor. Which of the following should the nurse suggest to the patient? 1. Parenteral opioids 2. Nitrous oxide 3. Epidural anesthesia 4. General anesthesia 1. Parenteral opioids Parenteral opioids are considered a medication and can cause neonatal respiratory depression, so they do not meet the criteria of the patient. Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered by the laboring woman using a mouth tube or face mask, when she determines that she needs it. It can be started and stopped at any point during labor, according to the needs and preferences of the woman. It takes effect in about 50 seconds after the first breath, and the effect is transient. It is has no adverse effects on the normal physiology and progress of labor. Epidural anesthesia involves placement of a very small catheter and injection of local anesthesia and or analgesia between the fourth and fifth vertebrae into the epidural space. It involves the administration of a medication and is rather involved to set up, so it does not meet the criteria of the patient. General anesthesia is not typically used in vaginal births. 5.A nurse is monitoring a woman's progress during active labor. The nurse observes that the woman's cervix has thinned and shortened dramatically in the past 15 minutes. The nurse recognizes that this phenomenon is known as which of the following? 1. Dilation 2. Effacement 3. Bearing down 4. Lightening 2. Effacement Dilation is the enlargement or opening of the cervical os. The cervix dilates from closed to 10 cm in diameter. Effacement is the shortening and thinning of the cervix. Before the onset of labor, the cervix is 2 to 3 cm long and approximately 1 cm thick. The degree of effacement is measured in percentage and goes from 0% to 100%. Bearing-down powers occur once the cervix is fully dilated (10 cm), and the woman feels the urge to push; she will involuntarily bear down. Lightening refers to the descent of the fetus into the true pelvis that occurs approximately 2 weeks before term in first-time pregnancies. A nurse is assisting a patient who has finished delivering her baby vaginally and is now delivering the placenta. The nurse recognizes that the woman is in which stage of labor? 1. First 2. Second 3. Third 4. Fourth 3. Third The first stage begins with the onset of labor and ends with complete cervical dilation. The second stage begins with complete dilation of the cervix and ends with delivery of the baby. The third stage begins after delivery of the baby and ends with delivery of the placenta. The fourth stage begins after delivery of the placenta and is completed 4 hours later; it is the immediate postpartum period. A woman entering the second stage of labor reports that she feels the urge to bear down. The nurse recognizes that this phenomenon is known as which of the following? 1. Ferguson's reflex 2. Valsalva technique 3. Lightening 4. Braxton-Hicks contraction 1. Ferguson's reflex The urge to push or bear down is known as Ferguson's reflex. The Valsalva technique involves holding one's breath while bearing down, also called closed glottis pushing. It does not refer to the urge to push. Lightening refers to the descent of the fetus into the true pelvis that occurs approximately 2 weeks before term in first-time pregnancies. Braxton-Hicks contractions are irregular uterine contractions that do not result in cervical change and are associated with false labor. In explaining to a patient factors that help the fetal head to mold during labor and birth and thus fit through the maternal pelvis, which of the following should the nurse mention? 1. The presence of membranous spaces between the bones (sutures) and fontanels of the fetal skull 2. The action of estrogen to soften cartilage and increase elasticity of the ligaments 3. The action of relaxin to soften cartilage and increase elasticity of the ligaments 4. The gender of the fetus 1. The presence of membranous spaces between the bones (sutures) and fontanels of the fetal skull Molding is the ability of the fetal head to change shape to accommodate/fit through the maternal pelvis. The membranous spaces between the bones (sutures) and fontanels of the fetal skull (intersections of these sutures) allow the skull bones to overlap and mold to fit through the birth canal. Estrogen and relaxin soften cartilage and increase elasticity of the ligaments of the woman's pelvis joints. This helps the fetal skull fit through the pelvis but is not a factor that causes the fetal head itself to mold. The gender of the fetus is not related to the ability of the fetal head to mold. A patient who is in labor has just experienced rupture of membranes. Which of the following should be priority actions for the nurse to take at this time? Select all that apply. 1. Assist the patient into the lithotomy position 2. Assess the fetal heart rate 3. Assess the amniotic fluid for color, amount, and odor 4. Instruct the woman to bear down with the urge to push 5. Document the date and time of rupture of membranes 2, 3, 5 2. Assess the fetal heart rate 3. Assess the amniotic fluid for color, amount, and odor 5. Document the date and time of rupture of membranes Feedback 1: Just because the patient's membranes have ruptured does not mean that she is ready to deliver the baby immediately, which would warrant the lithotomy position. Feedback 2: The nurse should assess the fetal heart rate as there is an increased risk of umbilical cord prolapse with rupture of membranes. Feedback 3: The nurse should assess the amniotic fluid for color, amount, and odor, as meconium-stained fluid may be an indication of fetal compromise in utero. Feedback 4: The woman should not be instructed to bear down with the urge to push until she is fully effaced and dilated, which do not necessarily coincide with the rupture of membranes. Feedback 5: The nurse should document the date and time of the rupture of membranes, characteristics of the fluid, and the fetal heart rate. A nurse is explaining to a patient the maternal factors that trigger labor. Which of the following should the nurse mention? Select all that apply. 1. Stretching of uterine muscles 2. Desire of the mother 3. Pressure on the cervix 4. Release of oxytocin 5. Increase in estrogen 1, 3, 4, 5 1. Stretching of uterine muscles 3. Pressure on the cervix 4. Release of oxytocin 5. Increase in estrogen Feedback 1: Uterine muscles are stretched to the threshold point, leading to release of prostaglandins that simulate contractions. Feedback 2: The desire of the mother is not a labor trigger, unfortunately. Feedback 3: Increased pressure on the cervix stimulates the nerve plexus, causing release of oxytocin by the maternal pituitary gland, which then stimulates contractions. Feedback 4: Oxytocin stimulates myometrial contractions. Oxytocin and prostaglandin work together to inhibit calcium binding in muscle cells, raising intracellular calcium levels and activating contractions. Feedback 5: Estrogen increases, stimulating the uterine response.