Which is the priority for nursing care during the second stage of labor quizlet?

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1. Science
2. Medicine
3. Obstetrics

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Terms in this set (79)

____ 1. A woman in the latent phase of labor is admitted with a diagnosis of group B Streptococcus. Which order should the nurse question?

Prepare for an amniotomy

____ 2. A patient is in active labor, 6 cm dilated, 100% effaced with intact amniotic membranes. Which procedure does the nurse anticipate?

Amniotomy

____ 3. The physician performs an amniotomy on a laboring woman. Which is the nurse's priority of care after the procedure?

Measuring fetal heart tones

____ 4. A woman in active labor has not progressed since reaching 6 cm dilation. Which is the nurse's priority of care?

Assisting with bladder emptying

____ 5. During contractions, which is the nurse's priority teaching for a woman in active labor?

Encouraging proper breathing and relaxation techniques

____ 6. A patient in the transition phase of labor is 8 cm dilated and reports feeling the need to push. Which is the nurse's priority teaching for this patient?

Assisting with pant-blow breathing

____ 7. After delivery of an infant and prior to delivery of the placenta, which is the priority assessment of the mother?

Condition of the cervix, vagina, and perineum

____ 8. Which is the nurse's priority of care during the immediate postdelivery period?

Care of the newborn

____ 9. A newborn has a 1-minute Apgar of 3 and a 5-minute Apgar of 5. When will the next Apgar be performed by the nurse?

At 10 minutes of life

____ 10. The nurse accepts a newborn from the provider immediately after delivery and assesses the 1-minute Apgar as 6. How does the nurse maintain thermoregulation for this newborn?

Place the infant on a radiant warmer

____ 11. A father who is watching the nurse prepare an injection of vitamin K for his infant asks why the medication is necessary. Which is the nurse's best explanation?

"It is given to promote blood clotting till the newborn begins eating."

____ 12. The nurse who is teaching a class for peers to explain the physiology of pain explains that somatic pain is caused by what?

Stretching of the perineum during fetal descent

____ 13. A woman in labor uses hypnosis to manage pain, which the nurse recognizes as a component of which method?

Dick-Read method

____ 14. A laboring patient has received IV fentanyl for labor pain management and requests it again after the cervical check indicates she is 10 cm dilated and ready to start pushing. Which is the nurse's best response to the patient's request?

"Administering a narcotic now could be dangerous because it will suppress the baby's breathing."

____ 15. The nurse is caring for a patient who received an epidural analgesic minutes ago. Which assessment finding should the nurse report to the provider immediately?

Shortness of breath, itching, and hives

____ 16. A multipara woman presents to the labor unit in active labor, dilated to 9 cm, and requesting something to manage the pain. Which anesthetic is most appropriate for this patient?

Spinal

____ 17. Which patient does the nurse consider at lowest risk for urinary retention?

The patient who received an IV narcotic for pain management

__ 18. The nurse is caring for a patient in labor with a known history of drug abuse. How does the patient's history impact the nursing plan of care?

Higher dosages of medications may be needed to manage this patient's pain.

____ 19. The nurse assesses a patient immediately after she receives an epidural anesthetic to control labor pain and notes tachycardia, hypertension, and reports of dizziness and a metallic taste in her mouth. Which is the nurse's priority intervention?

Notifying the provider immediately

____ 20. Which nonpharmacological pain relief measures can the nurse provide a laboring woman to ease the pain of contractions? (Select all that apply.)

Progressive relaxation
Breathing techniques
Diversion and distraction

Which maternal hormones are suspected of contributing to the onset of labor? (Select all that apply.)
1) Increased oxytocin levels
2) Increased prostaglandin levels
3) Reduced progesterone levels
4) Increased cortisol levels
5) Uterine stretch theory

1,2,3
1. Increased oxytocin is believed to stimulate the uterine muscle and contribute to the onset of labor.
2. An increase in prostaglandins produces cervical softening and increased uterine muscle sensitivity, which are believed to contribute to stimulating contractions.
3. Progesterone, produced by the placenta, hinders contractions, so a reduction in progesterone allows estrogen to stimulate contractions.
4. It is the fetus, not the mother, who produces cortisol.
5. Although the uterine stretch theory is believed to be a contributing factor to the onset of labor, it is not hormone related.

Which signs do the nurse observe in a woman who is in labor? (Select all that apply.)
1) Lightening
2) Cervical effacement
3) Cervical dilation
4) Burst of energy
5) Cervical softening

2,3
1. Lightening is the dropping of the fetus into the pelvis, which occurs at approximately 38 weeks' gestation, prior to the onset of labor.
2. Cervical effacement is the thinning of the cervix, which occurs during labor.
3. Cervical dilation is the opening of the cervical os, which occurs during labor.
4. The burst of energy women report generally occurs 24 to 48 hours before labor begins.
5. Cervical softening occurs in the last weeks of pregnancy, prior to the onset of labor, preparing the cervix for effacement and dilation.

Which cervical change does the nurse caring for a primipara expect to find during an assessment?
1) The cervix dilates first, then begins to efface.
2) Cervical dilation occurs at the same rate as cervical effacement.
3) Cervical effacement occurs slowly, before significant dilation occurs.
4) Cervical dilation begins; then effacement reaches 100% before dilation is complete.

3
1 Effacement, not dilation, occurs first in primiparas.
2 Multiparas efface and dilate at the same time, but primiparas do not.
3 The cervix of the primipara effaces slowly before significant dilation occurs.
4 Total effacement generally occurs with completion of dilation.

The triage nurse receives a call from a pregnant woman. Which statement by the pregnant woman makes the nurse suspect the woman is experiencing false labor?
1) "The pain is in my back and circles around to the front."
2) "The pain gets more intense when I walk."
3) "The pain is becoming more intense and more frequent."
4) "I've been timing the contractions, and they are not regular."

4
1 True labor often begins in the back and radiates to the front.
2 True labor intensifies with walking, whereas false labor does not.
3 Contractions become more intense and more frequent over time in true labor.
4 False labor contractions are irregular and do not become more intense.

The nurse reviews the medical record of a woman admitted in labor and sees she has a narrow pelvis. Which of the seven Ps of labor does this impact?
1) Passage
2) Passenger
3) Power
4) Presentation

1
1 The passage is impacted by a narrow pelvis and may impede the fetus' ability to move through the passage to be delivered vaginally.
2 The passenger is the fetus, who is not impacted by the size of the mother's pelvis.
3 Power is the strength of the uterine muscle for contracting and pushing the fetus, which is not impacted by a narrow pelvis.
4 Presentation describes the part of the fetus that delivers first according to how the fetus lies in the uterus, which is not impacted by a narrow pelvis.

When reviewing a laboring patient's medical record, the nurse sees that a longitudinal lie has been documented. How is the fetus positioned?
1) The fetus is lying parallel with the mother's body.
2) The fetus is lying perpendicular to the mother's body.
3) The fetus is lying at an angle to the mother's body, between parallel and perpendicular.
4) The fetus is in the head-down position.

1
1 A longitudinal lie means the fetus is lying parallel with the mother's body but does not indicate whether it is head-down or breach.
2 A transverse lie indicates the fetus is perpendicular to the mother's body.
3 An oblique lie describes a fetus that is lying at an angle between the transverse and longitudinal lie.
4 Presentation, not position, describes which body part of the infant will present first.

After reinforcing teaching on how to determine the duration of a contraction, the nurse determines further teaching is needed when the mother makes which statement?
1) "I will time from the end of one contraction to the end of the next contraction."
2) "As soon as the contraction stops, I will time until the next one begins."
3) "I will write down the exact time the contraction begins and ends."
4) "I will time from the beginning of one contraction till the beginning of the next one."

3
1 Timing from the end of one contraction to the end of the next does not reveal the duration of the contraction; this is a combination of duration and frequency, with neither clearly revealed.
2 Timing from the end of one contraction to the beginning of the next contraction reveals frequency of the contractions, not duration.
3 Timing from when a contraction begins until it ends reveals the duration of the contraction.
4 The time from the beginning of one contraction to the beginning of the next is the sum of the duration and frequency, with neither clearly revealed.

A student nurse is observed providing care to a woman in active labor. The instructor recognizes the need for corrective action when the student makes which statement?
1) "You're doing great with your breathing during contractions."
2) "Your partner could roll tennis balls over your back during contractions to reduce pain."
3) "Only your obstetrician can tell you how far your cervix has dilated."
4) "I will stay with you as long as I can to help you manage labor pain."

3
1 The patient's satisfaction is improved when support and reassurance are given during labor, so this is an appropriate statement requiring no corrective action.
2 Suggesting ways to manage pain improves patient satisfaction, so this is an appropriate statement requiring no corrective action.
3 The patient needs clear concise information about labor progress, so this statement requires the instructor's corrective intervention.
4 Continuous one-on-one support throughout labor by someone who can advocate for the woman's needs is appropriate, so this statement requires no corrective action.

Which assessment finding does the nurse recognize is the result of the laboring patient's increasing anxiety level as contractions become stronger?
1) Abnormal fetal heart rate patterns
2) Increased uterine contractility
3) Shorter second stage of labor
4) Reduced maternal heart rate

1
1 Abnormal fetal heart rate patterns can result from maternal anxiety and an increase in epinephrine production.
2 Uterine contractility reduces with anxiety and an increase in epinephrine production.
3 Anxiety results in longer active labor.
4 Anxiety causes the production of epinephrine, which increases maternal heart rate.

While being admitting, a patient in labor says, "I want plenty of narcotics so I am asleep until the baby comes." The nurse recognizes that meeting this request will cause which risk for cesarean section?
1) The patient's inability to push and participate in delivery
2) Risk for fetal harm secondary to medications passing through the placenta
3) Elimination of the partner's involvement in the labor and delivery process
4) Increased contractility of the uterus as a potential side effect

1
1 Excessive use of narcotics eliminates the patient's ability to push and participate in the delivery process, which can result in increased risk for a Cesarean section.
2 Although fetal sedation can occur secondary to the administration of narcotics, this does not increase the risk for Cesarean section.
3 There is no reason for narcotic administration to eliminate the partner's involvement, and this does not increase the risk for Cesarean section.
4 Use of narcotics does not increase the contractility of the uterus, so this is not a factor causing increased risk for Cesarean section.

Which is the priority of nursing care for a woman in the early latent phase of labor?
1) Encourage rest between contractions
2) Encourage activity such as walking
3) Perform frequent cervical checks
4) Encourage acceptance of pain medications

1
1 The first stage of labor can last up to 20 hours, so it is important for the woman to rest and conserve energy during the early latent phase.
2 Although walking helps to promote labor, this is not the priority of care in the early latent phase of labor.
3 Frequent cervical checks are not necessary until contractions become more frequent and last longer.
4 Pain during contractions can often be controlled with relaxation and breathing techniques.

After observing a laboring patient, the experienced nurse tells the student nurse that a cervical examination will likely confirm the transition phase has begun. What did the experienced nurse observe to suggest this diagnosis?
1) The woman reports that rupture of the membranes has occurred.
2) The woman keeps saying she is so glad to finally be in labor.
3) The contractions are 2 to 3 minutes apart.
4) The woman is irritable and has trouble concentrating.

4
1 Rupture of membranes can occur at any stage of labor so this would not indicate the transition phase.
2 A woman who is glad to finally be in labor is likely to be in early labor before the contractions become stronger and more frequent.
3 Contractions come more frequently than every 2-3 minutes during the transition phase.
4 One of the classic indications of the transition phase of labor occurs when the woman becomes irritable and has trouble concentrating.

While the doctor awaits delivery of the placenta after delivery of the newborn, the nurse documents that the patient is in which state of labor?
1) Latent
2) Second
3) Transition
4) Third

4
1 Latent stage is the first phase of the first stage of labor.
2 The second stage of labor occurs after complete dilation and ends with the birth of the newborn.
3 Transition is the third phase of the first stage of labor and lasts until the cervix has dilated to 10 cm.
4 The third stage of labor begins with the birth of the newborn and ends with delivery of the placenta, so the nurse documents that the woman is in the third stage of labor.

A laboring patient begins to demonstrate irritability, snapping at her labor coach and complaining of pelvic pressure. The nurse suspects cervical assessment will reveal which dilation measurement?
1) 2 to 3 cm
2) 4 to 5 cm
3) 5 to 6 cm
4) 8 to 9 cm

4
1 At 2 to 3 cm, the patient is in the latent phase of labor, which is not marked by irritability and pelvic pressure.
2 At 4 to 5 cm, the patient is in the latent phase of labor, which is not marked by irritability and pelvic pressure.
3 At 5 to 6 cm, the patient is in the latent phase of labor, which is not marked by irritability and pelvic pressure.
4 Irritability and pelvic pressure mark the transition phase of labor, when the cervix goes from 8 cm dilated to 10 cm dilated, so 8 to 9 cm fits in this range.

The nurse expects expulsion of the head to occur following which fetal movement?
1) Restitution and external rotation
2) Extension
3) Internal rotation
4) Flexion

1
1 Extension follows descent and flexion of the head, when the occiput comes into contact with the inferior margin of the symphysis pubis and the force of uterine contractions causes the occiput to extend and rotate around the symphysis, just before expulsion of the head.
2 Extension follows descent and flexion of the head, when the occiput comes into contact with the inferior margin of the symphysis pubis and the force of uterine contractions causes the occiput to extend and rotate around the symphysis.
3 Internal rotation occurs as the head, which is usually in the transverse position, rotates 45 degrees to an anterior-posterior position under the symphysis pubis of the pelvis.
4 Flexion occurs as the fetal head encounters resistance from the pelvic bones and soft tissues of the pelvic floor, causing the fetus to flex the head.

After handing a wrapped newborn to the mother, the nurse sees the umbilical cord lengthening and a sudden trickle of blood at the vaginal opening and recognizes what is about to happen?
1) Hemorrhage
2) Multiple birth
3) Placental separation
4) Uterine inversion

3
1 A trickle of blood at this time is not an indication of hemorrhage and is normal and expected.
2 These are not symptoms of a multiple birth, which would be indicated by presentation of the body part of another fetus.
3 These are indications of placental separation because some bleeding results and the umbilical cord appears to lengthen as the placenta is delivered.
4 Uterine inversion is indicated by the appearance of the fundus protruding from the vagina.

When assessing maternal response to labor, the nurse sees the most significant responses in which system?
1) Cardiovascular
2) Respiratory
3) Gastrointestinal
4) Reproductive

4
1 Although the cardiovascular system is impacted by labor, it is not the location of the most significant responses.
2 Although the respiratory system is impacted by labor, it is not the location of the most significant responses.
3 Although the gastrointestinal system is impacted by labor, it is not the location of the most significant responses.
4 The most significant responses during labor occur in the reproductive system.

Which finding does the nurse identify as unexpected and concerning when assessing a woman in labor during the peak of a contraction?
1) Increased blood pressure
2) Decreased pulse rate
3) Increase in depth and rate of respirations
4) White blood cell (WBC) count of 26,000/mm3

4
1 A decrease in blood to the placenta at the peak of contractions causes the woman's blood volume to increase, with a correlated rise in blood pressure and a decrease in pulse rate.
2 A decrease in blood to the placenta at the peak of contractions causes the woman's blood volume to increase, with a correlated rise in blood pressure and a decrease in pulse rate.
3 Anxiety and pain cause an increase in the rate and depth of respirations.
4 Although the WBC may be slightly elevated in the term woman, this WBC count is higher than the expected 14,000 to 16,000/mm3 and requires further assessment.

As the fetal head moves through the birth canal, the nurse expects which assessment finding?
1) Reduction in heart rate
2) Increase in fetal oxygen pressure
3) Decrease in fetal arterial carbon dioxide pressure
4) Increase in fetal breathing movements

1
1 As the fetal head moves through the birth canal, an expected assessment finding is reduction in heart rate due to head compression.
2 Fetal oxygen pressure is expected to decrease because of reduced fetal circulation and perfusion.
3 Fetal PCO2 is expected to rise because of reduced circulation and perfusion.
4 Fetal breathing movements decrease because of the pressure of the birth canal on the fetal chest.

A laboring patient asks the nurse if the baby is injured during the delivery process. Which response by the nurse demonstrates understanding of fetal response to labor and delivery?
1) "Circulation and perfusion stop during contractions, so it is important not to labor too long."
2) "The baby can't breathe, so carbon dioxide builds up in the bloodstream and the oxygen level falls."
3) "The stress of labor does not produce any ill effects for the baby as long as the baby is healthy."
4) "No one really knows what happens to the baby during delivery, but it is a normal process."

3
1 Although circulation and perfusion slow during the peak of a contraction, they do not stop, so this is not an accurate statement.
2 Removal of carbon dioxide and delivery of oxygen occur because of perfusion through the placenta, so fetal breathing is not required.
3 This is a true statement that will relieve the mother's concern because adverse effects do not result from labor in a healthy fetus.
4 This statement is not accurate because the impact of labor on the fetus is known; also, this statement does not reassure the mother.

A 30-year-old pregnant woman, gravida 1, para 0 is 30 weeks pregnant. She reports at her regularly scheduled office visit that she is experiencing vaginal bleeding that began "about three days ago." She also states, "I didn't call because I am not having any pain, and I can feel the baby moving." Which of the following would be the appropriate diagnostic procedure for her?

Abdominal ultrasound

A nurse is caring for a patient who just experienced a first trimester spontaneous abortion. Which comment by the nurse is considered appropriate? (Select all that apply.)

"If you have any questions, I am available to talk."

"Is there anyone I could call for you—a friend, pastor, or rabbi?"

Which of the following is a priority nursing intervention for a patient with a ruptured ectopic pregnancy?

Obtain IV access and begin infusing IV fluids.

The purpose of administering RhoGAM is to ____________ the mother from developing Rh antibodies.

Prevent

A woman at 38 weeks of gestation was involved in a car accident. She has numerous abrasions but no broken bones or head injury. The emergency department nurse knows that the most common complication that may occur for this woman is:

Placenta abruptio

Which of the following is a major risk factor for gestational diabetes?

Obesity

The most serious complication of a hydatidiform mole pregnancy is the development of:

Cancer

Patient teaching for the patient with pre-eclampsia should include which of the following?

Monitor blood pressure twice daily.

Why is magnesium sulfate administered to the pregnant patient with pre-eclampsia?

Reduce central nervous system irritability to prevent seizures.

Immediately after birth, the infant born to a mother with gestational diabetes should be monitored for which of the following?

Hypoglycemia

The nurse is describing true and false labor to a patient. Which of the following statements made by the patient indicates that she understands the difference?

"True labor contractions cause cervical changes."

The shortest phase of labor is usually the:

Transition phase

Which maternal positions are considered appropriate for labor? (Select all that apply.)

Side-lying
Sitting
Standing
Walking

Powers, as one of the "Seven Ps," refers to:

The uterine contractions and pushing efforts

Signs that the placenta is separating from the uterus are: (Select all that apply.)

A gush of blood comes from the uterus.

The umbilical cord lengthens.

Immediately after birth, the primary way to promote mother-infant bonding is to ensure ________.

skin-to-skin contact

What is the stage of labor when it is most appropriate to push?

The second stage

What does a station of -1 mean?

The fetal head is 1 cm above the ischial spines.

A woman is admitted in labor. Her hemoglobin is 12.6 g/dL. What does this indicate to the nurse?

The patient has a normal hemoglobin level.

A contraction began at 11:00:00 and ended at 11:00:30. The next contraction began at 11:05:00. How far apart were the two contractions?

4 minutes and 30 seconds

A patient in the active phase of labor begins to experience nausea and has become very irritable. What does this suggest is happening?

She is moving into the transition phase of labor.

A patient's membranes ruptured, and the contractions have become more intense over the last few minutes. Her blood pressure is 122/80 mm Hg, and the respiratory rate is 32 bpm. She is 6 cm dilated. She reports a feeling of numbness and tingling of her fingers. Which nursing action is appropriate for this situation?

Ask her to breathe into a paper bag.

A nurse is providing care for a patient in active labor. Which of the following signs should be reported to the charge nurse immediately? (Select all that apply.)

FHR of 200 bpm.

Membranes rupture with greenish fluid noted.

The patient has vaginal bleeding.

The laboring patient wants medication for pain management. The health-care provider has ordered butorphanol (Stadol) 1 mg IV. The patient asks the nurse if it is safe for the baby. What is the best response by the nurse?

"I am giving you a small dose so that the peak effect wears off before the baby is born. That reduces the risk of harm to the baby."

The nurse notes on the fetal monitor that the fetus is experiencing a late deceleration. Which nursing actions are appropriate in this situation? (Select all that apply.)

Turn the patient to her side.

Apply oxygen via face mask.

Which of the following are risk factors for preterm labor? (Select all that apply.)

Multiple gestation

Urinary tract infection

Bacterial vaginosis

A patient at 37 weeks' gestation is admitted to labor and delivery. Her membranes ruptured 12 hours ago at home. The monitor indicates that the FHR is 150 bpm with moderate variability, no variable or late decelerations, and no uterine contractions. The patient asks the nurse, "Why can't I stay at home until my labor begins?" What is the best reply by the nurse?

"We want to monitor you for signs of infection."

Which of the following statements regarding oligohydramnios is true?

The fetus may be small for gestational age.

Nursing care for a patient with PROM includes which of the following? (Select all that apply.)

Monitoring FHR and contractions

Administration of antibiotics if ordered

Monitoring the patient's vital signs

Which of the following are signs of an imminent precipitous delivery? (Select all that apply.)

A bulging perineum

The mother stating a desire to push

Increase in bloody show and mucus

Which pregnant patient is at greatest risk for macrosomia?

The primigravida woman who has diabetes

After a patient's membranes rupture, the nurse performs a vaginal examination and notices that the umbilical cord has fallen through the cervix into the vagina. Which of the following should the nurse do? (Select all that apply.)

Manually elevate the fetal head off the cord.

Place the patient in knee-chest position.

Apply oxygen via face mask.

Which of the following patients is at highest risk for uterine rupture?

A multigravida woman scheduled for her fourth cesarean birth

The nurse suspects that the patient may be developing an infection called chorioamnionitis. Which of the following could be the cause of this infection?

The patient's membranes ruptured 3 days ago.

A dysfunctional or abnormally slow progress in labor may be caused by which of the following? (Select all that apply.)

A narrow pelvis

A morbidly obese patient

A brow presentation of the fetus

Narcotic pain medication

•Begins with regular uterine contractions and ends with ________________.

...

Latent phase of labor:

1st part of the 1st stage of labor, lasts 4-6h, cervix 0-3cm, contractions irregular, mild to mod frequency 5-30m and duration of 30-45s, some dilation and effacement, pt talkative and eager
Use slow/ deep breathing

Active phase of labor:

4-7 cm
moderate to strong contractions
regular
q 3-5 min
lasts 40-70 sec

Performing an amniotomy, which is the artificial rupture of the membranes (AROM) with an amniohook

transition phase

the end of stage one labor as the fetus begins moving through the cervix and down the birth canal

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What is the priority nursing action during a client's second stage of labor?

Which is the priority nursing action for a client in the second stage of labor quizlet?

Which nursing action is performed during the second stage of labor?

Which of the following occurs during Stage 2 of labor?