upon her understanding of when the anterior frontal closes?
a.
2 months
b.
8 months
c.
12 months
d.
18 months
D
The larger of the two fontanels,
... [Show More] the anterior fontanel, closes by 18 months after birth. The posterior fontanel closes at 6 to 8
weeks. The remaining three options are too early for the anterior fontanel to close.
The nurse is performing an initial assessment of a client in labor. What is the appropriate terminology for the relationship of
the fetal body parts to one another?
a.
Lie
b.
Presentation
c. Attitude
d.
Position
C
Attitude is the relationship of the fetal body parts to one another. Lie is the relationship of the long axis (spine) of the fetus to
the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through
the birth canal during labor at term. Position is the relationship of the presenting part of the fetus to the four quadrants of the
mother's pelvis.
When assessing the fetus using Leopold's maneuvers, the nurse feels a round, firm, and movable fetal part in the fundal portion
of the uterus and a long, smooth surface in the mother's right side close to midline. What is the position of the fetus?
a.
ROA
b.
LSP
c.
RSA
d.
LOA
CF
etal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or the
left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for
the location of the presenting part in relationship to the anterior, posterior, or transverse portion of the maternal pelvis.
Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a
breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother's
right side denotes the location of the presenting part in the mother's pelvis. The ability to palpate the fetal spine indicates that
the fetus is anteriorly positioned in the maternal pelvis. This fetus is anteriorly positioned in the right side of the maternal
pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA
denotes a fetus that is anteriorly positioned in the right side of the maternal pelvis with the occiput as the presenting part. LSP
describes a fetus that is posteriorly positioned in the left side of the pelvis with the sacrum as the presenting part. A fetus that is
LOA would be anteriorly positioned in the left side of the pelvis with the occiput as the presenting part.
Which statement by the client would lead the nurse to believe that labor has been established?
a.
"I passed some thick, pink mucus when I urinated this morning."
b.
"My bag of waters just broke."
c.
"The contractions in my uterus are getting stronger and closer together."
d.
"My baby dropped, and I have to urinate more frequently now."
CR
egular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Although
the loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, it is not the
indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor; however, it is not an
indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor but is not
the indicator of true labor.
The nurse has received a report regarding a client in labor. The woman's last vaginal examination was recorded as 3 cm, 30%,
and -2. What is the nurse's interpretation of this assessment?
a.
Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
b.
Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
c.
Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
d.
Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.
B
The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the
relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and
effaced 30%, and the presenting part is 2 cm above the ischial spines. The first interpretation of this vaginal examination is
incorrect; the cervix is dilated 3 cm and is 30% effaced. However, the presenting part is correct at 2 cm above the ischial
spines. The remaining two interpretations of this vaginal examination are incorrect. Although the dilation and effacement are
correct at 3 cm and 30%, the presenting part is actually 2 cm above the ischial spines.
A pregnant woman is at 38 weeks of gestation. She wants to know whether there are any signs that "labor is getting close to
starting." Which finding is an indication that labor may begin soon?
a. Weight gain of 1.5 to 2 kg (3 to 4 lb)
b.
Increase in fundal height
c. Urinary retention
d.
Surge of energy
D
Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, as a result of water loss caused by
electrolyte shifts that, in turn, are caused by changes in the estrogen and progesterone levels. When the fetus descends into the
true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor.
Which stage of labor varies the most in length?
a.
First
b.
Second
c.
Third
d.
Fourth
A
The first stage of labor is considered to last from the onset of regular uterine contractions to the full dilation of the cervix. The
first stage is significantly longer than the second and third stages combined. In a first-time pregnancy, the first stage of labor
can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The
average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts
from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The
fourth stage of labor, recovery, lasts approximately 2 hours after the delivery of the placenta.
The nurse expects which maternal cardiovascular finding during labor?
a.
Increased cardiac output
b.
Decreased pulse rate
c. Decreased white blood cell (WBC) count
d.
Decreased blood pressure
A During each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system, which increases cardiac
output by approximately 10% to 15% during the first stage of labor and by approximately 30% to 50% in the second stage of
labor. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor,
uterine contractions cause systolic readings [Show Less]