Exam (elaborations)
N265: LABOR STAGES, A&P OF LABOR, FETAL MONITORING STUDY GUIDE WITH COMPLETE SOLUTION!!
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N265: LABOR STAGES, A&P OF LABOR, FETAL MONITORING STUDY GUIDE WITH COMPLETE SOLUTION!!
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N265: LABOR STAGES, A&P OF LABOR, FETAL MONITORINGSTUDY GUIDE WITH COMPLETE SOLUTION!!
The nurse is teaching the laboring client about the cardinal movements that a fetus
in the vertex position makes through the pelvis during the labor process. Arrange
those movements in order, beginning with the movement that occurs after
engagement and ending with the movement that occurs at birth. All options must
be used.
a. Flexion
b. Descent
c. Extension
d. Internal rotation
e. External rotation
Answers :B A D C E: The 7 cardinal movements of the mechanism of labor that
occur in a vertex presentation are engagement, descent, flexion, internal rotation,
extension, external rotation, and finally birth. Descent refers to the progress of the
presenting part through the pelvis. Flexion is when the chin is brought into closer
contact with the fetal chest. Internal rotation begins at the level of the ischial spines
but is not completed until the presenting part reaches the lower pelvis. Extension
occurs when the fetal head reaches the perineum for birth. The occiput passes
under the lower border of the symphysis pubis. After the head is born, it rotates
briefly to the position it occupied when it was engaged in the inlet. This is called
"external rotation."
The nurse is performing an assessment on a pregnant woman to determine whether
labor has begun. Which finding is a clinical sign of true labor?
a. The cervix is located in a posterior position.
b. The cervix demonstrates signs of softening.
c. Contractions are experienced at irregular intervals.
, d. Contractions are initially felt in the abdomen usually above the umbilicus.
Answers :B: The cervix shows progressive change (softening, effacement, and
dilation signaled by the appearance of bloody show) when the woman is
experiencing true labor. False labor is associated with the other presented options.
The nurse, caring for a client in the active stage of labor, is monitoring the fetal
status and notes that the monitor strip shows a late deceleration. Based on this
observation, which action would the nurse take immediately?
a. Document the findings.
b. Prepare for immediate birth.
c. Increase the rate of an oxytocin infusion.
d. Administer oxygen to the client via face mask.
Answers :D: Late decelerations are caused by uteroplacental insufficiency as the
result of decreased blood flow and oxygen transfer to the fetus through the
intervillous space during the uterine contractions. This causes hypoxemia;
therefore, oxygen is necessary. Although the finding needs to be documented,
documentation is not the priority action in this situation. Late decelerations are
considered an ominous sign but do not necessarily require immediate birth of the
baby. The oxytocin infusion should be discontinued when a late deceleration is
noted. The oxytocin would cause further hypoxemia because the medication
stimulates contractions and leads to increased uteroplacental insufficiency.
The nurse is caring for a client in active labor. Which intervention would the nurse
implement to prevent fetal heart rate decelerations?
a. Discourage the client from walking.
b. Increase the rate of the oxytocin infusion.
c. Encourage upright or side-lying maternal positions.
d. Monitor the fetal heart rate every 30 minutes.
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