1.A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A)“I'm feeling contractions mostly in my back.”
B)“My contractions are about 6 minutes apart and regular.” C)“The contractions slow down when I walk around.”
D)“If I try to talk to my partner during a contraction, I can't.” Ans:C
False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.
2.Which of the following would indicate to the nurse that the placenta is separating? A)Uterus becomes globular
B)Fetal head at vaginal opening
C)Umbilical cord shortens
D)Mucous plug is expelled
Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.
3.When assessing cervical effacement of a client in labor, the nurse assesses which of the following characteristics? A)Extent of opening to its widest diameter
B)Degree of thinning
C)Passage of the mucous plug
D)Fetal presenting part
Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.
4.A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which of the following? A)Increased energy level with alternating strong and weak contractions B)Moderately strong contractions every 4 minutes, lasting about 1 minute C)Contractions noted in the front of abdomen that stop when she walks D)Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds Ans:B
Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.
5.A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A)Supine
The use of any upright position helps to reduce the length of labor. Research validates that nonmoving back-lying positions such as supine and lithotomy positions during labor are not healthy. The knee–chest position would assist in rotating the fetus in a posterior position.
6.A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A)Latent phase of the first stage of labor
B)Active phase of the first stage of labor