Labor and Delivery Processes – ATI CH 11

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Who are the 3 clients an intrapartum nurse should care for during each labor and delivery?
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◯ Fetus ◯ Mother ◯ Family unit
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What are the physiologic changes that can precede labor?
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◯ Backache – a constant low, dull backache, caused by pelvic muscle relaxation ◯ Weight loss – a 0.5 to 1.4 kg (1 to 3 lb) weight loss ◯ Lightening – fetal head descends into true pelvis about 14 days before labor; feeling that the fetus has “dropped;” easier breathing, but more pressure on bladder, resulting in urinary frequency; more pronounced in clients who are primigravida ◯ Bloody show – brownish or blood-tinged mucus discharge caused by expulsion of the cervical mucus plug resulting from the onset of cervical dilation and effacement ◯ Energy burst – sometimes called “nesting” response
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When does a woman’s water break?
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Spontaneous ROM can initiate labor or can occur anytime during labor, most commonly during the transition phase. ■ Labor usually occurs within 24 hr of the rupture of membranes. ■ Prolonged rupture of membranes greater than 24 hr before delivery of fetus may lead to an infection. ■ Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse.
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When does the nurse assess the amniotic fluid and what are the characteristics that should be observed?
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◯ Assessment of amniotic fluid is completed once the membranes rupture ■ Should be watery, clear, and pale- to straw-yellow in color. ■ Odor should not be foul. ■ Volume is between 500 and 1,200 mL. ■ Nitrazine paper should be used by a nurse to confirm that amniotic fluid is present.
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When using Nitrazine paper to confirm ROM, how would the nurse differentiate between urine and amniotic fluid?
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☐ Amniotic fluid is alkaline: Nitrazine paper should be deep blue, indicating pH of 6.5 to 7.5. ☐ Urine is slightly acidic: Nitrazine paper remains yellow.
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What are the 5 “P’s” of labor and delivery?
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Passenger, Passageway Powers Position Psychological response
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1 PASSENGER
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Passenger – consists of the fetus and the placenta. The size of the fetal head, fetal presentation, lie, attitude, and position affect the ability of the fetus to navigate the birth canal. The placenta can be considered a passenger because it also must pass through the canal.
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2 PASSAGEWAY
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Passageway – the birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). The size and shape of the bony pelvis must be adequate to allow the fetus to pass through it. The cervix must dilate and efface in response to contractions and fetal descent.
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3 POWERS
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Powers – uterine contractions cause effacement and dilation of the cervix and descent of the fetus. Involuntary urge to push and voluntary bearing down in the second stage of labor helps in the expulsion of the fetus.
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4 POSITION
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Position – of the woman who is in labor. The client should engage in frequent position changes during labor to increase comfort, relieve fatigue, and promote circulation. Position during the second stage is determined by maternal preference, provider preference, and the condition of the mother and the fetus. ■ Gravity can aid in the fetal descent in upright, sitting, kneeling, and squatting positions.
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5 PSYCHOLOGICAL RESPONSE
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Psychological response – maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor.
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Presentation
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Presentation – the part of the fetus that is entering the pelvic inlet first. It can be the back of the head (occiput), chin (mentum), shoulder (scapula), or breech (sacrum or feet).
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Lie
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■ Lie – the relationship of the maternal longitudinal axis (spine) to the fetal longitudinal axis (spine). ☐ Transverse – fetal long axis is horizontal and forms a right angle to maternal axis and will not accommodate vaginal birth. The shoulder is the presenting part and may require delivery by cesarean birth if the fetus does not rotate spontaneously. ☐ Parallel or longitudinal – fetal long axis is parallel to maternal long axis, either a cephalic or breech presentation. *Breech presentation may require a cesarean birth.
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Attitude (flexion/extension)
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■ Attitude – relationship of fetal body parts to one another. ☐ Fetal flexion – chin flexed to chest, extremities flexed into torso. ☐ Fetal extension – chin extended away from chest, extremities extended.
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Fetal Position
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■ Fetopelvic or fetal position – the relationship of the presenting part of the fetus (sacrum, mentum, or occiput), preferably the occiput, in reference to its directional position as it relates to one of the four maternal pelvic quadrants. It is labeled with three letters. ☐ The first letter references either the right (R) or left (L) side of the maternal pelvis. ☐ The second letter references the presenting part of the fetus, either occiput (O), sacrum (S), mentum (M), or scapula (Sc). ☐ The third letter references either the anterior (A), posterior (P), or transverse (T) part of the maternal pelvis.
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Station
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☐ Station – measurement of fetal descent in centimeters with station 0 being at the level of an imaginary line at the level of the ischial spines, minus stations superior to the ischial spines, and plus stations inferior to the ischial spines.
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What are the common preprocedure nursing actions for the labor and birth process?
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Leopold maneuvers External electronic monitoring (tocotransducer) External fetal monitoring (EFM)
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Leopold maneuvers
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Abdominal palpation to assess: Number of fetuses Fetal presenting part Lie Attitude Descent Probable location of fetal heart tones
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External electronic monitoring (tocotransducer)
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■ External electronic monitoring (tocotransducer): separate transducer applied to the maternal abdomen over the fundus that measures uterine activity. ☐ Displays uterine contraction patterns ☐ Easily applied by the nurse but must be repositioned with maternal movement to ensure proper placement
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External fetal monitoring (EFM)
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■ External fetal monitoring (EFM) – transducer applied to the abdomen of the client to assess FHR patterns during labor and birth.
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What lab tests are done preceding the labor and birth process?
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Group B streptococcus Urinalysis
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Why is the Group B streptococcus lab test before the labor and birth process begins?
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■ Group B streptococcus – culture is obtained if results are not available from screening at 36 to 37 weeks. ☐ If positive, intravenous prophylactic antibiotic is prescribed (exceptions are planned cesarean birth and membranes intact).
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Why is a urinalysis done preceding the L&D process?
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■ Urinalysis – clean-catch urine sample obtained to ascertain maternal: ☐ Hydration status via specific gravity ☐ Nutritional status via ketones ☐ Proteinuria, which is indicative of gestational hypertension ☐ Urinary tract infection via bacterial count
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Which blood tests are important preceding the L&D process?
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☐ Hct level ☐ ABO typing and Rh-factor if not previously done
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What are the Intraprocedure nursing actions for Labor and Birth Process?
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Assess maternal vital signs Check maternal temperature Assess FHR to determine fetal well-being Assess uterine labor contraction characteristics Assess intrauterine pressure
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When should the nurse check maternal temperature?
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Check maternal temperature every 1 to 2 hr if membranes are ruptured.
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What are the options for assessing FHR?
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Assessment of FHR may be performed by use of EFM or spiral electrode that is applied to the fetal scalp. ☐ Prior to electrode placement, cervical dilation and rupture of membranes must occur.
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What are the characteristics of labor contractions that should be evaluated by the nurse?
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☐ Frequency – established from the beginning of one contraction to the beginning of the next. ☐ Duration – the time between the beginning of a contraction to the end of that same contraction. ☐ Intensity – strength of the contraction at its peak described as mild, moderate, or strong. ☐ Resting tone of uterine contractions – tone of the uterine muscle in between contractions.
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What would be cause for concern when monitoring labor contractions?
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A prolonged contraction duration of >90 seconds Continuous contractions (More than 5 contractions in a 10-min period without sufficient time for uterine relaxation) *Back to back contractions that are <30 seconds in between can reduce blood flow to the placenta. This can result in fetal hypoxia and decreased FHR.
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Intrauterine Pressure Catheter
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■ Insert a solid, sterile, water-filled intrauterine pressure catheter inside the uterus to measure intrauterine pressure. ☐ Displays uterine contraction patterns on monitor. ☐ Requires the membranes to be ruptured and the cervix to be sufficiently dilated.
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Why is a vaginal examination performed during the labor process?
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■ Vaginal examination – performed digitally by the provider or qualified nurse to assess for the following: ☐ Cervical dilation (stretching of cervical os adequate to allow fetal passage) and effacement (cervical thinning and shortening) ☐ Descent of the fetus through the birth canal as measured by fetal station in centimeters ☐ Fetal position, presenting part, and lie ☐ Membranes that are intact or ruptured
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Characteristics of FALSE labor
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■ Contractions: » Painless, irregular frequency, and intermittent » Decrease in frequency, duration, and intensity with walking or position changes » Felt in lower back or abdomen above umbilicus » Often stop with sleep or comfort measures such as oral hydration or emptying of the bladder ■ Cervix (assessed by vaginal exam): » No significant change in dilation or effacement » Often remains in posterior position » No significant bloody show ■ Fetus: » Presenting part is not engaged in pelvis
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Characteristics of TRUE labor
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■ Contractions: » May begin irregularly, but become regular in frequency » Stronger, last longer, and are more frequent » Felt in lower back, radiating to abdomen » Walking can increase contraction intensity » Continue despite comfort measures ■ Cervix (assessed by vaginal exam): » Progressive change in dilation and effacement » Moves to anterior position » Bloody show ■ Fetus: » Presenting part engages in pelvis
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Mechanism of labor
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■ Mechanism of labor – the adaptations the fetus makes as it progresses through the birth canal during the birthing process. ☐ Engagement ☐ Descent ☐ Flexion ☐ Internal rotation ☐ Extension ☐ Restitution and external rotation ☐ Expulsion
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Engagement
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Engagement – occurs when the presenting part, usually biparietal (largest) diameter of the fetal head passes the pelvic inlet at the level of the ischial spines. Referred to as station 0.
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Descent
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Descent – the progress of the presenting part (preferably the occiput) through the pelvis. Measured by station during a vaginal examination as either negative (-) station measured in centimeters if superior to station 0 and not yet engaged, or positive (+) station measured in centimeters if inferior to station 0.
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Flexion
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Flexion – when the fetal head meets resistance of the cervix, pelvic wall, or pelvic floor. The head flexes, bringing the chin close to the chest, presenting a smaller diameter to pass through the pelvis.
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Internal rotation
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Internal rotation – the fetal occiput ideally rotates to a lateral anterior position as it progresses from the ischial spines to the lower pelvis in a corkscrew motion to pass through the pelvis.
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Extension
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Extension – the fetal occiput passes under the symphysis pubis, and then the head is deflected anteriorly and is born by extension of the chin away from the fetal chest.
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Restitution and external rotation
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Restitution and external rotation – after the head is born, it rotates to the position it occupied as it entered the pelvic inlet (restitution) in alignment with the fetal body and completes a quarter turn to face transverse as the anterior shoulder passes under the symphysis.
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Expulsion
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Expulsion – after birth of the head and shoulders, the trunk of the neonate is born by flexing it toward the symphysis pubis.
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STAGES OF LABOR
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FIRST STAGE (inc. 3 phases): onset of labor – full dilation SECOND STAGE: full dilation – birth THIRD STAGE: delivery of neonate – delivery of placenta
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FIRST STAGE OF LABOR
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FIRST STAGE: LABOR Onset of labor – Full Dilation INCLUDES 3 PHASES: Latent phase – 0 to 3 cm Active phase – 4 to 7 cm Transition – 8 to 10 cm
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STAGE 1 – Latent phase
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0 to 3 cm Latent phase – begins: Cervix 0 cm Contractions irregular, mild to moderate, occurring every 5 to 30 min, lasting 30 to 45 seconds Mom – some dilation and effacement, talkative and eager Latent phase – ends: Cervix 3 cm Lasts 4 to 6 hours avg.
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STAGE 1 – Active phase
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4 to 7 cm Active phase – begins: Cervix 4 cm Contractions regular Moderate to strong, every 3 to 5 min, lasting 40 to 70 sec. Mom: Rapid dilation and effacement Some fetal descent Feelings of helplessness Anxiety and restlessness increase as contractions become stronger Active phase – ends: Cervix 7 cm Lasts 2 to 3 hours avg.
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STAGE 1 – Transition phase
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8 to 10 cm Transition phase – begins: Cervix 8 cm Contractions – Strong to very strong contractions Frequency 2 to 3 min Duration 45 to 90 seconds Mom: › Tired, restless, and irritable › Feeling out of control, client often states, “cannot continue” › May have N & V › Urge to push › Increased rectal pressure › Increased bloody show › Most difficult part of labor Transition phase – ends: Complete dilation at 10 cm Lasts 20 to 40 min avg.
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SECOND STAGE OF LABOR
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2nd STAGE – PUSHING Full dilation – birth Progresses to intense contractions every 1 to 2 min Pushing results in birth of fetus › Primigravida: 30 min to 2 hr › Multigravida: 5 to 30 min
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THIRD STAGE OF LABOR
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3rd STAGE – DELIVERY Delivery of neonate – delivery of placenta › Placental separation and expulsion › Shiny Schultz presentation: shiny fetal surface of placenta emerges first › Dirty Duncan presentation: dull maternal surface of placenta emerges first › 5 to 30 min
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FOURTH STAGE OF LABOR
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4th STAGE – RECOVERY Delivery of placenta – Mom return to prepregnancy state › Maternal stabilization of vital signs › Lochia scant to moderate rubra › 6 wks postpartum
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Nursing Assessments During the Fourth Stage
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■ Maternal vital signs ■ Fundus ■ Lochia ■ Perineum ■ Urinary output ■ Maternal/newborn baby-friendly activities
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Nursing Interventions During the Fourth Stage
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■ Assess maternal vital signs every 15 min for the first hour and then according to facility protocol. ■ Assess fundus and lochia every 15 min for the first hour and then according to facility protocol. ■ Massage the uterine fundus and/or administer oxytocics as prescribed to maintain uterine tone to prevent hemorrhage. ■ Assess the client’s perineum, and provide comfort measures as indicated. ■ Encourage voiding to prevent bladder distention. ■ Promote an opportunity for maternal/newborn bonding.
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What client education should the nurse include for the fourth stage of labor?
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Instruct the client to notify the nurse of increased vaginal bleeding or passage of blood clots. Offer assistance with breastfeeding, and provide reassurance.
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A nurse in the labor and delivery unit receives a phone call from a client who reports that her contractions started about 2 hr ago, did not go away when she had two glasses of water and rested, and became stronger since she started walking. Her contractions occur every 10 min and last about 30 seconds. She hasn’t had any fluid leak from her vagina. However, she saw some blood when she wiped after voiding. Based on this report, the nurse should recognize that the client is experiencing A. Braxton Hicks contractions. B. rupture of membranes. C. fetal descent. D. true contractions.
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ANS: D – True contractions do not go away with hydration or walking. A. INCORRECT: Braxton Hicks contractions decrease with hydration and walking. B. INCORRECT: Rupture of membranes would be indicated by the presence of a gush of fluid that is unrelated to the client’s activity. C. INCORRECT: Fetal descent is the downward movement of the fetus in the birth canal and cannot be evaluated based on the client’s report. D. CORRECT: True contractions do not go away with hydration or walking. They are regular in frequency, duration, and intensity and become stronger with walking.
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A nurse in the labor and delivery unit is caring for a client in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are every 8 min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is this client experiencing? A. The first stage, latent phase B. The first stage, active phase C. The first stage, transition phase D. The second stage of labor
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ANS: A – The first stage, latent phase A. CORRECT: In stage 1, latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds. B. INCORRECT: In stage 1, active phase, the cervix dilates from 4 to 7 cm, and contraction duration ranges from 40 to 70 seconds. C. INCORRECT: In stage 1, transition phase, the cervix dilates from 8 to 10 cm, and contraction duration ranges from 45 to 90 seconds. D. INCORRECT: The second stage of labor consists of the expulsion of the fetus.
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A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. The nurse’s first nursing action after establishing that the fluid is amniotic fluid should be to A. assess the amniotic fluid for meconium. B. monitor the FHR for distress. C. dry the client and make her comfortable. D. monitor the client’s uterine contractions.
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ANS: B – monitor the FHR for distress A. INCORRECT: The nurse assesses the color, clarity, odor, and amount of amniotic fluid, but this is not the first action the nurse should take. B. CORRECT: The greatest risk to the client and fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. Therefore, the first action by the nurse is to monitor the FHR for signs of distress. C. INCORRECT: The nurse should provide comfort by drying the client following rupture of the membranes, but this is not the first action the nurse should take. D. INCORRECT: The nurse monitors the client’s uterine contraction pattern after rupture of the membranes, but this is not the first action the nurse should take.
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A nurse in labor and delivery is completing an admission history for a client who is at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2 days. The nurse knows that this client is at risk for A. cord prolapse. B. infection. C. postpartum hemorrhage. D. hydramnios.
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ANS: B – infection A. INCORRECT: Although cord prolapse is a risk with rupture of membranes, it occurs when the fluid rushes out, rather than trickling or leaking out. B. CORRECT: Rupture of membranes for longer than 24 hr prior to delivery increases the risk that infectious organisms will enter the vagina and then eventually into the uterus. C. INCORRECT: The risk for postpartum hemorrhage by this client is not any greater than other clients who are pregnant. D. INCORRECT: This client is more likely to have oligohydramnios or insufficient amniotic fluid, rather than hydramnios, or excess amniotic fluid.
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5. A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The client is very irritable and feels the urge to have a bowel movement. She states, “I’ve had enough. I can’t do this anymore. I want to go home right now.” The nurse knows that these signs indicate the client is in the A. second stage of labor. B. fourth stage of labor. C. transition phase of labor. D. latent phase of labor.
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ANS: C – transition phase of labor A. INCORRECT: The second stage of labor occurs with the expulsion of the fetus. B. INCORRECT: The fourth stage of labor is the recovery period, following the delivery of the placenta. C. CORRECT: The transition phase of labor occurs when the client becomes irritable, feels rectal pressure similar to the need to have a bowel movement, and can become nauseous with emesis. D. INCORRECT: The latent phase of labor occurs in stage one, and coincides with mild contractions. The client is more relaxed, talkative, and eager for labor to progress.
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The manager of a labor and delivery unit is reviewing the procedure for vaginal examination with a group of newly hired nurses. Which of the following interventions should be included in this discussion? A. Nursing Actions: Describe four actions that are preprocedure, intraprocedure, and postprocedure.
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● Explain procedure, and obtain client’s permission for the examination. ● Don sterile glove with antiseptic solution or soluble gel for lubrication. ● Position the client to avoid supine hypotension. ● Provide for privacy. ● Cleanse the vulva or perineum if needed. ● Insert index and middle finger into the client’s vagina. ● Explain findings to the client. ● Document findings, and report to the provider.
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The manager of a labor and delivery unit is reviewing the procedure for vaginal examination with a group of newly hired nurses. Which of the following interventions should be included in this discussion? B. Describe three assessment findings that can be determined by the procedure.
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● Cervical dilation, effacement, and position ● Fetal presenting part, position, and station ● Status of membranes ● Characteristics of amniotic fluid if membranes ruptured

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