LABOR AND DELIVERY PROCESS

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate?

• 
  cervix

• sacral promontory

• symphysis pubis

• ischial spines

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear?

• 
  "I need ice chips because I'm so hot."

• "I have to push the baby out right now!"

• "I can't stand this pain any longer!"

• "I am so excited to be in labor."

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude?

• the woman has an internal lacteration

• the woman is ready to expel the cord bloods

• the woman has an atonic uterus

• the woman is about to deliver the placenta

A nurse is teaching a class of pregnant couples the most therapeutic breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach?

• alternately panting and blowing

• slow chest breathing

• grunting and pushing with contractions

• rapid, deep breathing

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect the client is at this time?

• 2 cm

• 
  8 cm

• 4 cm

• 10 cm

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:

• Uterine atony

• Hematoma

• Placental separation

• Placenta previa

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean?

• 
  The fetal lie is horizontal

• The fetus is in an extended attitude

• The fetus has become engaged

• The fetal head has entered the true pelvis

On examination, it is noted that a full-term primipara in active labor is right occipitoanterior (ROA), 7 cm dilated, and 3+ station. Which of the following should the nurse report to the physician?

• descent is progressing well

• external rotation is complete

• 
  fetal head is not yet engaged

• vaginal delivery is imminent

A multipara, LOA, station +3, who has had no pain medication during labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate?

• "Epidurals do not work well when the pain level is above level 5"

• "I will check the fetal heart rate. You can have an epidural if it is over 120."

• "The baby is going to be born very soon. It is really too late for an epidural."

• "I will contact the doctor to get an order for an epidural right away."

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result?

• 
  administer oxygen to the woman via face mask

• awaken the woman and remind her to push

• assess the woman's blood pressure and pulse

• cover the woman's perineum with a sheet