When caring for a laboring patient, the nurse determines during a vaginal exam that the baby's
head has internally rotated. She explains to the student nurse that this process is called the
mechanisms of labor which are also called cardinal movements and are described as:
a) Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation and Expulsion
b) Descent, Internal Rotation, Extension, External Rotation and Expulsion
c) Descent, Flexion, Internal Rotation, Extension and Delivery
d) Engagement, Flexion, Internal Rotation, External Rotation and Delivery - Answers a)
Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation and Expulsion
During the fourth stage of labor, one hour after delivery, your client's assessment includes a BP
of 120/70, pulse 95, and the fundus is firm, midline and 2 finger breaths below the umbilicus.
The priority action of the nurse should be to:
a) Turn the client on her left side
b) Place the bed in Trendelenburg position
c) Massage the fundus
d) Continue to monitor - Answers d) Continue to monitor
The therapeutic plan of care for a client with a prolonged latent phase of labor should include
which intervention as a priority measure:
a) Measure maternal blood pressure, temperature and pulse every 15 minutes.
b) Continuous internal fetal monitoring of the fetal response to contractions.
c) IV hydration with either lactated Ringer's solution or 5 percent dextrose
d) Encouraging rest and relaxation through the playing of soft music - Answers d) Encouraging
rest and relaxation through the playing of soft music
A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following
data: cervical dilation 7cm, mild contractions, every 2-3 minutes lasting 50-60 seconds. Which
manifestation in this data does not fit the pattern suggested by the rest of the cues?
, a) Cervical dilatation 7cm
b) Contractions 50-60 seconds
c) Mild contractions
d) Contraction frequency ever 2-3 minutes - Answers c) Mild contractions
During the initial intrapartal assessment of a client in early labor, the midwife performs a vaginal
examination. The client's partner asks the nurse why this pelvic exam needs to be done. The
nurse should explain that the purpose of the vaginal examination is to obtain information about:
Select All That Apply
a) Uterine contraction pattern
b) Cervical dilatation and effacement
c) Fetal position
d) Presenting fetal part
e) Fetal heart rate - Answers b) Cervical dilatation and effacement
c) Fetal position
A woman is admitted to the birth unit. She is bearing down uncontrollably with contractions and
says, "The baby is coming!" What should be the priority action of the nurse?
a) Telephone the healthcare provider.
b) Put on gloves and prepare for immediate birth.
c) Obtain a medical and obstetric history.
d) Assess maternal vital signs and fetal heart rate. - Answers b) Put on gloves and prepare for
immediate birth.
A 28-year-old gravida 2 comes to the birth. The contractions are every three minutes and 60
seconds. Her membranes are intact, and the cervix is 5cm dilated and 90% effaced with the
vertex at a +1 station. During the admission interview, the client tells the nurse that she has
Type I diabetes, and that she gave birth to a term stillborn infant two years ago. The nurse
decides that in this situation, the best method for assessing the fetus is: