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Terms in this set (44)The nurse measures the frequency of a laboring woman's contractions by noting: a. how long the patient states the contractions last. d. the time between the beginning of one contraction and the beginning of the next. 2. The relaxation phase between contractions is important because the:a. laboring woman needs to rest. a. laboring woman needs to rest. c. contractions can interfere with fetal oxygenation. 3. The nurse recognizes the contraction duration and interval that could result in fetal compromise is: a. duration shorter than 30 seconds, interval longer than 75 seconds. c. duration longer than 90 seconds, interval shorter than 60 seconds. 4. Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. This presentation is referred to as: a. vertex. a. vertex. 5. When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates: a. fetal distress. a. fetal distress. 6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. The nurse would record this presentation as: a. complete breech. b. frank breech. 7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by: a. contractions that are relieved by walking. d. regular contractions becoming more frequent and intense. 8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. The nurse's most informative response would be that the woman should come when she: a. feels increased fetal
movement. c. thinks her membranes have ruptured. 9. The nurse caring for a woman in the first stage of labor reminds the patient that contractions during this stage of labor: a. get the infant positioned for delivery. c. dilate and efface the cervix. 10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, the nurse assesses the most likely explanation for the woman's change in behavior is that: a. labor has progressed to the transition phase. a. labor has progressed to the transition phase. 11. The nurse explains that the function of contractions during the second stage of labor is to: a. align the infant into the proper position for delivery. c. push the infant out of the mother's body 12. The nurse explains that the third stage of labor ends with: a. full cervical dilation. b. expulsion of the placenta and membranes. 13. During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may: a. interfere with cervical dilation. d. predispose the mother to uterine hemorrhage. 14. When the nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" The nurse should: a. go find the physician. b. stay with the woman and use the call bell to get help.
15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of: a. a well-oxygenated fetus. a. a well-oxygenated fetus. 16. The nurse would coach the laboring woman with a fully dilated cervix to push by saying: a. "At the beginning of a contraction, hold your breath and push for 10 seconds." d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation." 17. The most important nursing activity during the fourth stage of labor is to: a. monitor the frequency and intensity of contractions. c. assess for hemorrhage. 18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. The nurse should: a. check the fundus for position and firmness. a. check the fundus for position and firmness. 19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurse's initial action is to: a. stop the oxytocin infusion. c. reposition the woman to her side. 20. To relieve perineal bruising and edema following delivery the nurse should: a. place an ice pack on the area for 12 hours. a. place an ice pack on the area for 12 hours. 21. At 1 and 5 minutes of life, a newborn's Apgar score is 9. The nurse understands that a score of 9 indicates this newborn: a. will require resuscitation. d. is in stable condition. 22. The husband of a woman in labor asks, "What does it mean when the baby is at minus 1 station?" After giving an explanation, the nurse determines that teaching was effective when the husband states the fetal head is: a. above the ischial spines. a. above the ischial spines. 23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is: a. pain related to increasing frequency and intensity of contractions. d. risk for injury related to hemorrhage. 24. The nurse caring for a patient who is not certain if she is in true labor will attempt to stimulate cervical effacement and intensify contractions in the patient by: a. offering the patient warm fluids to drink. b. helping the patient to ambulate in room. 25. When late decelerations occur, the nurse should: a. reposition the patient to supine. c. increase oxygen to 10 L/minute. 26. The nurse takes into consideration that the primary concern in the initial care of the newborn is maintaining: a. fluid intake. c. thermoregulation. 27. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which intervention(s)? Select all that apply. a. Provide for extreme modesty. a. Provide for extreme modesty 28. What are the advantages of a free-standing birth center? Select all that apply. a. Home-like setting a. Home-like setting 29. What do late decelerations indicate? Select all that apply. a. A nonreassuring pattern a. A nonreassuring pattern The nurse measures the frequency of a laboring woman's contractions by noting: how long the patient states the contractions last. the time between the end of one contraction and the beginning of the next the time between the beginning and the end of one contraction the time between the beginning of one contraction and the beginning of the next the time between the beginning of one contraction and the beginning of the next At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by: contractions that are relieved by walking discomfort in the abdomen and groin regular contractions becoming more frequent and intense a decrease in vaginal discharge regular contractions becoming more frequent and intense The nurse explains that the function of contractions during the second stage of labor is to: align the infant into the proper position for delivery dilate and efface the cervix push the infant out of the mother's body separate the placenta from the uterine wall push the infant out of the mother's body The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is: fear related to the probable need for cesarean delivery dysuria related to prolonged labor and decreased intake risk for injury related to hemorrhage risk for injury related to hemorrhage A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. The nurse explains that giving a narcotic analgesic medication at this stage of labor will: have no complications for the mother or infant result in respiratory depression to the newborn speed up labor and increase pain result in respiratory depression to the newborn The nurse assessing the fundus of the uterus immediately after delivery would expect to find the uterus: relaxed with its upper border level with the umbilicus well-contracted with its upper border at or just below the umbilicus. well-contracted with its upper border three or four fingerbreadths above the umbilicus. relaxed with its upper border two or three fingerbreadths below the umbilicus well-contracted with its upper border at or just below the umbilicus. The hormone responsible for milk "let-down" or ejection from the breasts is estrogen prolactin progesterone oxytocin oxytocin The nurse assisting with deliveries is aware that which of the following clients is most at
risk for having a difficult delivery and possibly cesarean section. b) A woman whose baby is in the footling breech position c) A woman whose baby has a cephalic presentation d) A woman whose baby is in a longitudinal lie b) A woman whose baby is in the footling breech position A primigravida who is 2 weeks away from her delivery date tells the obstetrical nurse that she feels like "the baby has dropped." What would be the nurse's best response to this client? a) "This is a normal feeling called lightening signaling that labor has begun." b) "This feeling may be a sign that there is a complication with your pregnancy." c) "This is a normal feeling at this stage and it is called 'Braxton-Hicks' contractions." d) "This feeling is called lightening and means that the fetus has settled into the pelvis." d) "This feeling is called lightening and means that the fetus has settled into the pelvis." A pregnant client in her 38th week of gestation complains of abdominal pains and suspects she is in labor. Which of the following findings are characteristic of true labor contractions: ) Contractions help create effacement and dilation of the cervix. Contractions help create effacement and dilation of the cervix. A client in the first stage of labor has an episode of bright-red bleeding. What is the best action for the nurse to take? ) Report any bleeding at once. b) Perform an ultrasound examination, as ordered. c) Inject vitamin K, as ordered, to stop bleeding. d) Perform a vaginal examination per protocol. Report any bleeding at once. The nurse caring for a postpartum client explains the occurrence of lochia following delivery. Which of the following statements accurately describe a characteristic of this process? b) "Lochia serosa, which is pink or brown tinged, starts after the bleeding diminishes." c) "Lochia ruba, which is mostly red and bloody, is seen for the first week." d) "Lochia alba has a pungent, foul odor." b) "Lochia serosa, which is pink or brown tinged, starts after the bleeding diminishes." A 27 year old female gave birth via emergency caesarian delivery to a 38 week gestation 8 pound baby boy. Originally this mother had planned to breast feed, but since she had to have an emergency caesarian, she has opted to bottle feed instead.The new mother is complaining of breast soreness and enlargement. On assessment the nurse notes that the mothers breast are hot to touch, hard, shiny and red. Her pain scale rating is an 8 out of 10. She also complains of a headache and has a slightly elevated tempature of 98.9 F. The nurses first action would to be: address the pain and administer 1.5mg of Morphine PRN for pain per MD order address the pain and tell the new mother to take a hot shower to relieve the pain in her breasts To drink lots of fluids to prevent dehydration and to flush the infection from her system address the pain and administer acetaminophen as ordered PRN address the pain and administer acetaminophen as ordered PRN The nurse knows that she should include what teaching to the patient listed in the previous question? Instruct the mother to wear a supportive bra at all times, reduce stimulation to the breast and she may apply cold packs to her breast several times through out the day. Instruct the mother to express her milk to relieve the pressure in her breasts and to apply warm soaks to her breast several times during the day. Instruct the mother to feed the baby often to assist in milk supply. Instruct the mother how to use a breast pump and be avaialbe for any questions the mother may have. Instruct the mother to wear a supportive bra at all times, reduce stimulation to the breast and she may apply cold packs to her breast several times through out the day. At the beginning of the nurses shift, the nurse begins the assessment of a newly delivered patient. After asking the patient to urinate and lie flat, the nurse notes upon assessment the fundus is contracted
and at the level of the umbilicus. contacts the physician because the fundus is to remain soft and boggy at all times otherwise the patient could hemorrhage massages the fundus every 2-4 hours for the remainder of the shift because without doing this the patient may hemorrhage. does not massage the fundus because the nurse knows that massaging an already contracted fundus can cause it to invert and result in an emergency situation. checks for Homan's sign and continues the head to toe assessment, the Homan's sign is much more important than the fundus at this point does not massage the fundus because the nurse knows that massaging an already contracted fundus can cause it to invert and result in an emergency situation. Students also viewedD3 Essen82 terms jesslovescookies IT exam module 124 terms Nabil06252005Plus What MN1 said would be on test25 terms zachobert Cyber Sys Ops Mod 358 terms Ezra_Lewis6 Other sets by this creatorACLS 201545 terms gege7 Kaplan exit131 terms gege7 Cardiovascular Adult Health138 terms gege7 Adult 3 Cardiac Test Drugs and Lab Values37 terms gege7 Verified questions
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Which nursing action is performed during the second stage of labor quizlet?During the second stage of labor the client is encouraged to push, not pant, with each contraction. Catheterization may be indicated earlier in labor so uterine contractions are not impeded; voiding will occur spontaneously as the client pushes.)
What happens during Stage 2 of a normal delivery quizlet?Stage 2: Delivery - The mother pushes, and the baby crowns and then exits the birth canal and enters the world. Stage 3: Expelling of Placenta & Umbilical Cord - Contractions continue as the placenta and umbilical cord are expelled.
Which nursing action is performed during the second stage of labor?The second stage of labor may take from 15 to 30 minutes to several hours. Your primary nurse will help you with breathing and pushing techniques. You will be encouraged to push with your contractions, holding your breath as you do so.
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What is the function of contractions during the second stage of labor quizlet?
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