Ricci Chapter 13 - Test Bank - 4th Edition

1. A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is 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."

Answer: C

Rationale: 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. A client is in the third stage of labor. Which finding would alert 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

Answer: A

Rationale: 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

characteristic?

A. extent of opening to its widest diameter

B. degree of thinning

C. passage of the mucous plug

D. fetal presenting part

Answer: B

Rationale: 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 symptom?

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

Answer: B

Rationale: 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

B. lithotomy

C. upright

D. knee-chest

Answer: C

Rationale: The use of any upright position helps to reduce the length of labor. Research shows

that women who assumed the upright position during the first stage of labor experienced

significant improvement in the progress of labor, faster fetal head descent, significant reduction

of pain, and a good Apgar score. Additionally, studies show that recumbent positions result in

supine hypotension, diminishing uterine activity and reducing the dimensions of the pelvic

outlet. 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

about 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. perineal phase of the first stage of labor.

C. late active phase of the first stage of labor.

D. early phase of the third stage of labor.

Answer: C

Rationale: Late in the active phase of labor, contractions become more frequent (every 2 to 5

minutes) and increase in duration (45 to 60 seconds). The woman's discomfort intensifies

(moderate to strong by palpation). She becomes more intense and inwardly focused, absorbed in

the serious work of her labor. She limits interactions with those in the room. The latent phase is

characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and

effacement of 0% to 40%, and excitement and frequent talking by the mother. The pelvic phase

of the second stage of labor is characterized by complete cervical dilation and effacement, with

strong contractions every 2 to 3 minutes; the mother focuses on pushing. The perineal phase of

the second stage is the period of active pushing. The third stage, placental expulsion, starts after

the newborn is born and ends with the separation and birth of the placenta

7. The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the

client for which type of birth?

A. cesarean

B. vaginal

C. forceps-assisted

D. vacuum extraction

Answer: A

Rationale: The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a

cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

8. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%,

and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines

that this client is in:

A. latent phase of the first stage.

B. active phase of the first stage.

C. pelvic phase of the second stage.

D. early phase of the third stage.

Answer: A

Rationale: The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm,

cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45

seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40%

to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal

phase of the second stage occurs with complete cervical dilation and effacement, contractions

occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by

the mother. The third stage, placental expulsion, starts after the newborn is born and ends with

the separation and birth of the placenta.

9. A client is admitted to the labor and birthing suite in early labor. On review of her prenatal

history, the nurse determines that the client's pelvic shape as identified in the antepartal progress

notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have

noted?

A. platypelloid

B. gynecoid

C. android

D. anthropoid

Answer: B

Rationale: The most favorable pelvic shape for vaginal birth is the gynecoid shape. The

anthropoid pelvis is favorable for vaginal birth, but it is not the most favorable shape. The

android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is

slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually

require cesarean birth.

10. A woman telephones the prenatal clinic and reports that her water just broke. Which

suggestion by the nurse would be most appropriate?

A. "Call us back when you start having contractions."

B. "Come to the clinic or emergency department for an evaluation."

C. "Drink 3 to 4 glasses of water and lie down."

D. "Come in as soon as you feel the urge to push."

Answer: B

Rationale: When the amniotic sac ruptures, the barrier to infection is gone, and there is the

danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that

the woman come in for an evaluation. Calling back when contractions start, drinking water, and

lying down are inappropriate because of the increased risk for infection and cord prolapse.

Telling the client to wait until she feels the urge to push is inappropriate because this occurs

during the second stage of labor.

11. A nurse is conducting a continuing education program for a group of nurses working in the

perinatal unit. After reviewing information about the maternal bony pelvis with the group, the

nurse determines that the teaching was successful based on which statement by the group?

A. The bony pelvis plays a lesser role during labor than soft tissue.

B. The pelvic outlet is associated with the true pelvis.

C. The false pelvis lies below the imaginary linea terminalis.

D. The false pelvis is the passageway through which the fetus travels.

Answer: B

Rationale: The maternal bony pelvis consists of the true and false portions. The true pelvis is

made up of three planes—the inlet, the mid pelvis, and the outlet. The bony pelvis is more

important part of the passageway because it is relatively unyielding. The false pelvis lies above the imaginary linea terminalis. The true pelvis is the bony passageway through which the fetus

must travel.

12. A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the

buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which

type of breech presentation?

A. frank

B. full

C. complete

D. footling

Answer: A

Rationale: In a frank breech, the buttocks present first, with both legs extended up toward the

face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling

breech, one or both legs are presenting.

13. A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the

woman reports that her breathing has become much easier in the last week but she has noticed

increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event

has most likely occurred?

A. cervical dilation

B. lightening

C. bloody show

D. Braxton Hicks contractions

Answer: B

Rationale: Lightening occurs when the fetal presenting part begins to descend into the maternal

pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes

as a result of the change in the uterus. The woman usually notes that her breathing is much

easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain.

Although cervical dilation also may be occurring, it does not account for the woman's

complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during

pregnancy. It occurs with the onset of labor. Braxton Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They

also help in ripening and softening the cervix.

14. A nurse is conducting an in-service program for a group of nurses working in the labor and

birth suite of the facility. After teaching the group about the factors affecting the labor process,

the nurse determines that the teaching was successful when the group identifies which

component as part of the true pelvis? Select all that apply.

A. pelvic inlet

B. cervix

C. mid pelvis

D. pelvic outlet

E. vagina

F. pelvic floor muscles

Answer: A, C, D

Rationale: The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic

outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

15. A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse

documents the fetal lie. Which term would the nurse use?

A. flexion

B. extension

C. longitudinal

D. cephalic

Answer: C

Rationale: Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis

(spine) of the mother. There are three primary lies: longitudinal, oblique, and transverse. Flexion

and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal

presentation.

16. The nurse is reviewing the medical record of a woman in labor and notes that the fetal

position is documented as LSA. The nurse interprets this information as indicating which part as

the presenting part?

A. occiput

B. face

C. buttocks

D. shoulder

Answer: C

Rationale: The second letter denotes the presenting part which in this case is "S" or the sacrum or

buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would

denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or

shoulder presentation.

17. A nurse is preparing a class for pregnant women about labor and birth. When describing the

typical movements that the fetus goes through as it travels through the passageway, which

movements would the nurse include? Select all that apply.

A. internal rotation

B. abduction

C. descent

D. pronation

E. flexion

Answer: A, C, E

Rationale: The positional changes that occur as the fetus moves through the passageway are

called the cardinal movements of labor and include engagement, descent, flexion, internal

rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or

pronation.

18. The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a

contraction. The nurse notes the time the contraction takes from its onset to reach its highest

intensity. The nurse interprets this time as which phase?

A. increment

B. acme

C. peak

D. decrement

Answer: A

Rationale: Each contraction has three phases: increment or the buildup of the contraction; acme

or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The

time from the onset to the highest intensity corresponds to the increment.

19. A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for

concern during a contraction?

A. heart rate increase from 76 bpm to 90 bpm

B. blood pressure rise from 110/60 mm Hg to 120/74

C. white blood cell count of 12,000 cells/mm3

D. respiratory rate of 10 breaths/minute

Answer: D

Rationale: During labor, the mother experiences various physiologic responses including an

increase in heart rate by 10 to 20 bpm, a rise in blood pressure by up to 35 mm Hg during a

contraction, an increase in white blood cell count to 25,000 to 30,000 cells/mm3, perhaps as a

result of tissue trauma, and an increase in respiratory rate with greater oxygen consumption due

to the increase in metabolism. A drop in respiratory rate would be a cause for concern.

20. A nurse is caring for several women in labor. The nurse determines that which woman is the

latent phase of labor?

A. contractions every 5 minutes, cervical dilation 3 cm

B. contractions every 3 minutes, cervical dilation 6 cm

C. contractions every 2 1/2 minutes, cervical dilation 8 cm

D. contractions every 1 minute, cervical dilation 9 cm

Answer: A

Rationale: Contractions every 5 minutes with cervical dilation of 3 cm is typical of the latent

phase. Contractions every 3 minutes with cervical dilation of 6 cm, contractions every 2½

minutes with cervical dilation of 8 cm, and contractions every 1 minute with cervical dilation of

9 cm suggest the active phase of labor.

21. A nurse is preparing a presentation for a group of pregnant women about the labor

experience. Which factors would the nurse include when discussing measures to promote coping

for a positive labor experience? Select all that apply.

A. presence of a support partner

B. view of birth as a stressor

C. low anxiety level

D. fear of loss of control

E. participation in a pregnancy exercise program

Answer: A, C, E

Rationale: Numerous factors can affect a woman's coping ability during labor and birth. Having

the presence and support of a valued partner during labor, engaging in exercise during

pregnancy, viewing the birthing experience as a meaningful rather than stressful event, and a low

anxiety level can promote a woman's ability to cope. Excessive anxiety may interfere with the

labor progress, and fear of labor and loss of control may enhance pain perception, increasing the

fear.

22. During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think

I will be in labor?" Which response by the nurse would be most appropriate?

A. "It's difficult to predict how your labor will progress, but we'll be there for you the entire

time."

B. "Since this is your first pregnancy, you can estimate it will be about 10 hours."

C. "It will depend on how big the baby is when you go into labor."

D. "Time isn't important; your health and the baby's health are key."

Answer: A

Rationale: It is difficult to predict how a labor will progress and therefore equally difficult to

determine how long a woman's labor will last. There is no way to estimate the likely strength and

frequency of uterine contractions, the extent to which the cervix will soften and dilate, and how much the fetal head will mold to fit the birth canal. We cannot know beforehand whether the

complex fetal rotations needed for an efficient labor will take place properly. All of these factors

are unknowns when a woman starts labor. Telling the woman an approximate time would be

inappropriate because there is no way to determine the length of labor. It is highly

individualized. Although fetal size and maternal and fetal health are important considerations,

these responses do not address the woman's concern.

23. A nurse is describing how the fetus moves through the birth canal. Which component would

the nurse identify as being most important in allowing the fetal head to move through the pelvis?

A. sutures

B. fontanelles

C. frontal bones

D. biparietal diameter

Answer: A

Rationale: Sutures are important because they allow the cranial bones to overlap in order for the

head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the

maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones,

along with the parietal and occipital bones are bones of the cranium that are soft and pliable. The

biparietal diameter is an important diameter that can affect the birth process.

24. Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of

the maternal ischial spines. The nurse documents this as which station?

A. -2

B. -1

C. 0

D. +1

Answer: C

Rationale: Station refers to the relationship of the presenting part to the level of the maternal

pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or

plus, depending on its location above or below the ischial spines. Zero (0) station is designated

when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is

below the ischial spines, the distance is recorded as plus stations.

25. A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of

labor. When describing this stage to the client, which event would the nurse identify as the major

change occurring during this stage?

A. regular contractions

B. cervical dilation (dilatation)

C. fetal movement through the birth canal

D. placental separation

Answer: B

Rationale: The primary change occurring during the first stage of labor is progressive cervical

dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal

movement through the birth canal is the major change during the second stage of labor. Placental

separation occurs during the third stage of labor.

26. A nurse is providing care to a woman in labor. The nurse determines that the client is in the

active phase based on which assessment findings? Select all that apply.

A. cervical dilation of 6 cm

B. contractions every 2 to 3 minutes

C. cervical effacement of 30%

D. contractions every 90 seconds

E. strong desire to push

Answer: A, B

Rationale: During the active phase, the cervix usually dilates from 6 to 10 cm, with 40% to 100%

effacement taking place. Contractions become more frequent, occurring every 2-5 min and

increase in duration (45 to 60 seconds). Effacement of 30% reflects the latent phase.

Contractions occurring every 90 seconds suggest the second stage of labor. A strong urge to

push reflects the later perineal phase of the second stage of labor.

27. A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse,

"Yesterday, I had this burst of energy and cleaned everything in sight, but I don't know why."

Which response by the nurse would be most appropriate?

A. "You had a burst of epinephrine, which is common before labor."

B. "You were trying to get everything ready for your baby."

C. "You felt your mind telling you that you were about to go into labor."

D. "You were looking forward to the birth of your baby."

Answer: A

Rationale: Some women report a sudden increase in energy before labor. This is sometimes

referred to as nesting because many women will focus this energy toward childbirth preparation

by cleaning, cooking, preparing the nursery, and spending extra time with other children in the

household. The increased energy level usually occurs 24 to 48 hours before the onset of labor. It

is thought to be the result of an increase in epinephrine (adrenaline) release caused by a decrease

in progesterone. The burst of energy is unrelated to getting everything ready, the mind telling the

woman that she will be going into labor, or looking forward to the birth.

28. A nurse is conducting a class for a group of nurses new to the labor and birth unit about labor

and the passage of the fetus through the birth canal. As part of the class, the nurse explains that

specific diameters of the fetal skull can affect the birth process. Which diameter would the nurse

identify as being most important in affecting the birth process? Select all that apply.

A. Occipitofrontal

B. Occipitomental

C. Suboccipitobregmatic

D. Biparietal

E. Diagonal conjugate

Answer: C, D

Rationale: The diameter of the fetal skull is an important consideration during the labor and birth

process. Fetal skull diameters are measured between the various landmarks of the skull.

Diameters include occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal. The two

most important diameters that can affect the birth process are the suboccipitobregmatic

(approximately 9.5 cm at term) and the biparietal (approximately 9.25 cm at term) diameters.

Diagonal conjugate is a measure of the pelvic inlet of the mother.

29. Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and

engagement has occurred. The nurse interprets this finding to indicate that the presenting part is

at which station?

A. -2

B. -1

C. 0

D. +1

Answer: C

Rationale: Fetal engagement signifies the entrance of the largest diameter of the fetal presenting

part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to

be engaged in the pelvis when the presenting part reaches 0 station.

30. A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation

with the presenting part tilted toward the left side of the mother's pelvis and directed toward the

anterior portion of the pelvis. When developing this client's plan of care, which intervention

would the nurse include?

A. implementing measures for a vaginal birth

B. preparing the client for a cesarean birth

C. assisting with artificial rupture of the membranes

D. instituting continuous internal fetal monitoring

Answer: A

Rationale: The fetal presentation and position is left occiput anterior position or LOA, which is

the most common and most favorable fetal position for birth. LOA along with right occiput

anterior position are optimal positions for vaginal birth. Therefore the nurse should implement

measures for a vaginal birth. This fetal presentation is not an indication for cesarean birth. Nor is

there need for artificially rupturing the membranes. Continuous internal fetal monitoring would

be warranted if the woman or fetus was considered to be high risk.