Perry: Maternal Child Nursing Care, 4th Edition

Chapter 15: Labor and Birth Processes Test Bank MULTIPLE CHOICE 1. A new mother asks the nurse when the soft spot on her sons head will go away. The nurses answer is based on the knowledge that the anterior fontanel closes after birth by _____ months. a. 2 c. 12 b. 8 d. 18 ANS: D The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning REF: 376

2. When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: a. Lie. c. Attitude. b. Presentation. d. Position. ANS: C Attitude is the relation of the fetal body parts to one another. Lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relation of the presenting part to the four quadrants of the mothers pelvis. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 377

3. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mothers right side close to midline. What is the likely position of the fetus? a. ROA c. RSA b. LSP d. LOA ANS: C

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The fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 377, 378

4. The nurse has received a report about a woman in labor. The womans last vaginal examination was recorded as 3 cm, 30%, and -2. The nurses interpretation of this assessment is that: a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines. b. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. c. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines. d. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines. ANS: B The correct description of the vaginal examination for this woman in labor is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment, Planning REF: 378

5. What position would be least effective when gravity is desired to assist in fetal descent? a. Lithotomy c. Sitting b. Kneeling d. Walking ANS: A

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The predominant position in the United States for physician-attended births is the lithotomy position, which requires a woman to be in a reclined position with her legs in stirrups. Gravity has little effect in this position. Kneeling, sitting, and walking help align the fetus with the pelvic outlet and allow gravity to assist in fetal descent. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning, Implementation REF: 385, 386

6. Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? a. Semirecumbent c. Squatting b. Sitting d. Side-lying ANS: C The squatting position may help increase the pelvic outlet. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Implementation REF: 385

7. To adequately care for a laboring woman, the nurse knows that which stage of labor varies the most in length? a. First c. Third b. Second d. Fourth ANS: A The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning REF: 387, 388

8. The nurse would expect which maternal cardiovascular finding during labor? a. Increased cardiac output b. Decreased pulse rate c. Decreased white blood cell (WBC) count d. Decreased blood pressure

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ANS: A During each contraction 400 ml of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 10%, to 155, in the first stage of labor and by about 30% to 50% in the second stage. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor uterine contractions cause systolic readings to increase by about 10 mm Hg. During the second stage contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis REF: 390

9. The factors that affect the process of labor and birth, known commonly as the five Ps, include all except: a. Passenger. c. Powers. b. Passageway. d. Pressure. ANS: D The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 376

10. The slight overlapping of cranial bones or shaping of the fetal head during labor is called: a. Lightening. c. Ferguson reflex. b. Molding. d. Valsalva maneuver. ANS: B Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mothers sensation of decreased abdominal distention, which usually occurs the week before labor. Fetal head formation is called molding. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. Fetal head formation is called molding. The Valsalva maneuver describes conscious pushing during the second stage of labor. Fetal head formation is called molding. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 376

11. Which presentation is described accurately in terms of both presenting part and frequency of occurrence? a. Cephalic: occiput; at least 95% c. Shoulder: scapula; 10% to 15% b. Breech: sacrum; 10% to 15% d. Cephalic: cranial; 80% to 85% ANS: A
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In cephalic presentations (head first) the presenting part is the occiput; this occurs in 96% of births. In a breech birth the sacrum emerges first; this occurs in about 3% of births. In shoulder presentations the scapula emerges first; this occurs in only 1% of births. In a cephalic presentation the part of the head or cranium that emerges first is the occiput; cephalic presentations occur in 96% of births. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis REF: 377

12. With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that: a. The fetal attitude describes the angle at which the fetus exits the uterus. b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother. c. The normal attitude of the fetus is called general flexion. d. The transverse lie is preferred for vaginal birth. ANS: C The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal body parts to one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning REF: 377

13. With regard to fetal positioning during labor, nurses should be aware that: a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b. Birth is imminent when the presenting part is at +4 to +5 cm, below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d. Engagement is the term used to describe the beginning of labor. ANS: B The station of the presenting part should be noted at the beginning of labor so that the rate of descent can be determined. Position is the relation of the presenting part of the fetus to the four quadrants of the mothers pelvis; station is the measure of degree of descent. The largest diameter usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparas and before or during labor in multiparas. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 378

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14. Which basic type of pelvis includes the correct description and percentage of occurrence in women? a. Gynecoid: classic female; heart shaped; 75% b. Android: resembling the male; wider oval; 15% c. Anthropoid: resembling the ape; narrower; 10% d. Platypelloid: flattened, wide, shallow; 3% ANS: D A platypelloid pelvis is flattened, wide, and shallow; about 3% of women have this shape. The gynecoid shape is the classical female shape, slightly ovoid and rounded; about 50% of women have this shape. An android, or malelike, pelvis is heart shaped; about 23% of women have this shape. An anthropoid, or apelike, pelvis is oval and wider; about 24% of women have this shape. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 381, 383

15. With regard to primary and secondary powers, the maternity nurse should know that: a. Primary powers are responsible for effacement and dilation of the cervix. b. Effacement generally is well ahead of dilation in women giving birth for the first time; they are more together in subsequent pregnancies. c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. d. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs. ANS: A The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in first-timers; they are more together in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning REF: 384, 385

16. With regard to the position of the laboring woman, maternity nurses should be able to tell the woman that: a. The supine position commonly used in the United States increases blood flow. b. The all fours position, on her hands and knees, is hard on her back. c. Frequent changes in position will help relieve her fatigue and increase her comfort. d. In a sitting or squatting position her abdominal muscles will have to work harder. ANS: C

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Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The all fours position is used to relieve backache in certain situations. In a sitting or squatting position the abdominal muscles work in greater harmony with uterine contractions. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning, Implementation REF: 385

17. Which description of the four stages of labor is correct for both definition and duration? a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour ANS: A Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours). PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis REF: 388

18. With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that: a. The seven critical movements must progress in a more or less orderly sequence. b. Asynclitism sometimes is achieved by means of the Leopold maneuver. c. The effects of the forces determining descent are modified by the shape of the womans pelvis and the size of the fetal head. d. At birth the baby is said to achieve restitution (i.e., a return to the C-shape of the womb). ANS: C The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the babys head; the Leopold maneuver is a means of judging descent by palpating the mothers abdomen. Restitution is the rotation of the babys head after the infant is born. PTS: 1 DIF: Cognitive Level: Comprehension REF: 388

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Test Bank OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning, Implementation 19. To assess the health of the mother accurately during labor, the nurse should be aware that: a. The womans blood pressure will increase during contractions and fall back to prelabor normal between contractions. b. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. c. Having the woman point her toes will reduce leg cramps. d. The endogenous endorphins released during labor will raise the womans pain threshold and produce sedation.

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ANS: D The endogenous endorphins released during labor will raise the womans pain threshold and produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mothers perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor for a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning MULTIPLE RESPONSE 1. Signs that precede labor include (choose all that apply): a. Lightening. b. Exhaustion. c. Bloody show. d. Rupture of membranes. e. Decreased fetal movement. ANS: A, C, D Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning, Implementation 2. What factors influence cervical dilation? Choose all that apply. a. Strong uterine contractions
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REF: 387

Test Bank b. c. d. e. The force of the presenting fetal part against the cervix The size of the female The pressure applied by the amniotic sac Scarring of the cervix

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ANS: A, B, D, E Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size does not affect cervical dilation. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning COMPLETION 1. A ____________________ pelvic shape is ideal for a vaginal birth. ANS: Gynecoid PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 381, 383 REF: 384, 385

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