Labor - Questions and Answers with Explanations

Labor - Questions and Answers with Explanations The nurse anticipates that the physician will most likely order a cervicovaginal fetal fibronectin test for which client? 1. The client at 34 weeks' gestation with gestational diabetes 2. The client at 32 weeks' gestation with regular uterine contractions 3. The client at 37 weeks' multi-fetal gestation 4. The client at 20 weeks' gestation with ruptured amniotic membranes Explanation: 2. The absence of cervicovaginal fFN between 20 and 34 weeks' gestation has been shown to be a strong predictor of a woman not experiencing preterm birth due to spontaneous preterm labor or premature rupture of membranes. Positive findings indicate a 99% probability of birth within the next 2 weeks. A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? 1. Second phase 2. Latent phase 3. Active phase 4. Transition phase Explanation: 2. In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions. The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum 2. Increased bloody show 3. Spontaneous rupture of the membranes 4. Uncontrollable urge to push 5. Inability to breathe through contractions Explanation: 1. As the fetal head continues its descent, the perineum begins to bulge, flatten, and move anteriorly. 2. Bloody show increases as a woman enters the second stage of labor. 4. As the fetal head descends, the woman has the urge to push because of pressure of the fetal head on the sacral and obturator nerves. The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Select all that apply. 1. Maternal exhaustion 2. Cervical edema 3. Tearing and bruising of the cervix 4. Enhanced perineal thinning 5. Having to perform an episiotomy Explanation: 1. If the cervix is not completely dilated, maternal exhaustion can occur. 2. If the cervix is not completely dilated, cervical edema can occur. 3. If the cervix is not completely dilated, tearing and bruising of the cervix can occur. The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the client alone so she can rest. 2. Ask the family to take a coffee-and-snack break. 3. Encourage the client to have an epidural for pain. 4. Reassure the client that she will not be left alone. Explanation: 4. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression Explanation: 4. Variable decelerations occur when there is umbilical cord compression. The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? 1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen. ..................