Study Guide Answer Key Chapter 61
chapter
Study Guide Answer Key
Learning Activities
1. a. Powers
b. Passage
c. Passenger
d. Psyche
2. Uterine contractions, maternal pushing
3. a. Percentage of its original length
b. Centimeters
4. a. 90 seconds, 60 seconds, 2 minutes
b. The placenta does not receive oxygen-
carrying maternal blood when the uterus
is tightly contracted. Excessive duration of
contractions or inadequate uterine relax-
ation could reduce fetal oxygen supply.
5. a. Allow fetal head to change shape and ac-
commodate to the size and shape of the
maternal pelvis.
b. Provide landmarks to determine how the
fetus is oriented within the mothers pel-
vis.
6. a. Right sacrum anterior (breech)
b. Left mentum transverse (face presentation)
c. Right occiput anterior (most common)
d. Left occiput posterior (back labor)
7. Change in cervical effacement and/or dilation
8. a. Latent (14 cm dilation; 46 hours)
b. Active (47 cm dilation and effacement;
26 hours)
c. Transition (710 cm and complete efface-
ment; 2 hours)
9. a. First stage
i. Latent phase: cooperative, alert, talk-
ative, welcomes diversions, frequent
urination, thirsty
ii. Active phase: apprehensive, anxious,
introverted, less social, focused on
breathing, perspires, facial flushing, re-
quests pain relief, fears losing control;
may need pain relief
iii. Transition phase: irritable, rejects sup-
port persons, introverted, wants to
give up, restless, leg tremors, fears los-
ing control, requests pain relief
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6
b. Second stage: bulging perineum, passage
of stool, spontaneous pushing or urge to
push, states that baby is coming, exhaus-
tion after each contraction, unable to fol-
low directions easily, excitement about im-
minent birth
c. Third stage: elation, relief, tremors, in-
creased energy, curious about baby, desires
to nurse baby, minimal pain with placental
expulsion
d. Fourth stage: time for parents and new
baby to get acquainted, mother nurses
baby
10. a. 110120 BPM, 150160 BPM
b. Presence of variability and accelerations
are expected in a term labor, but may be
depressed by maternal narcotic administra-
tion or preterm gestation.
11. Cloudy yellow fluid (suggests infection); fluid
with a strong odor (infection); fluid containing
meconium
12. a. 100.4 F (38 C) or higher
b. 140/90 mm Hg or higher, systolic below 90
mm Hg
c. Outside normal limits of 110120 BPM
(lower limit) or 150160 BPM (upper limit)
at term
Review Questions
1. Answer: 1
Rationale: The normal range (1) for the FHR
at term is 110160 BPM, so 125 BPM is normal
regardless of whether the fetus is preterm (2);
it is not high normal (3), which would be more
in the range of 150160 BPM, nor is in a slow
baseline (4), which would be more in the range
of 110120 BPM.
2. Answer: 1
Rationale: The duration is the average length of
contractions, timed from the beginning to the
end of each contraction (1), not from its peak
to its end (4). Duration of a contraction never
1
2Study Guide Answer Key Chapter 6

includes the time between one contraction and 9. Answer: 1

the next, whether taken from ending of one to Rationale: LSA stands for left sacrum ante-
the beginning of the next (2), or from the begin- rior, meaning that the fetal breech is in the
ning of one to the start of the next (3). mothers left anterior pelvic quadrant (1). ROA
3. Answer: 2 (3) stands for right occipitoanterior; LOA (2)
Rationale: As labor progresses, the interval be- stands for left occipitoanterior; these two repre-
tween contractions gradually shortens (2), rath- sent the most favorable for normal labor. When
er than lengthens (3 and 4), and contractions the occiput faces the posterior section of the
become longer (2), not shorter (1), and stronger. womans pelvis, a longer, back labor birth
4. Answer: 2 process is anticipated. FHR (4) stands for fetal
Rationale: Normal amniotic fluid is clear (2), heart rate.
sometimes with flecks of white vernix. Am- 10. Answer: 2
niotic fluid is cloudy (1) and/or yellow (4) if Rationale: Clear, nonirritating vaginal secre-
intrauterine infection is present. Amniotic fluid tions (2) often increase as labor approaches. An
containing meconium is green (3). urge to push (1) usually characterizes onset of
5. Answer: 2 second stage labor. Active bleeding (3) (as op-
Rationale: Thinning of the cervix is effacement posed to bloody show near term or during la-
(2). Dilation (1) describes cervical opening. Sta- bor) during pregnancy is not normal. A woman
tion (3) describes fetal descent. Cervical efface- often loses about 1 to 3 pounds near the onset
ment and dilation often occur simultaneously, of labor, as opposed to a sudden weight gain
especially during the more active phase. Pre- (4).
sentation (4) describes the fetal part first enter- 11. Answer: 3
ing pelvis, usually the head. Rationale: The ischial spines in the mothers
6. Answer: 3 pelvis (3) are the reference point for measuring
Rationale: ROP stands for right occiput poste- fetal descent, as opposed to using the perine-
rior, meaning that the fetal occiput (3), not the um, sacrum, or uterine fundus (1, 2, and 4).
sacrum (1) or fetal pelvis (2) is in the right pos- 12. Answer: 4
terior quadrant of the mothers pelvis (3), as Rationale: Schultze (S = Shiny) (4) describes the
opposed to the right fetal occiput being in the exit of the fetal side of the placenta. Duncan (1)
mothers posterior pelvis (4). describes placental expulsion with the dull ma-
7. Answer: 3 ternal side presenting (D = Dull). Lamaze (2) is
Rationale: Transition (3) is the last part of the a method of childbirth preparation. VBAC (3)
first stage; typical maternal behaviors include is an acronym for vaginal birth after cesarean.
anxiety, possible loss of control, and wanting 13. Answer: 2
labor to be over. These behaviors may be dif- Rationale: Women in latent labor are often
ferent if the woman has epidural analgesia. slightly anxious, but usually cope well with
The latent (1) phase comes first, and the patient labor at this time (2). Sleepy except during
is cooperative, alert, and talkative. Active (2) contractions (1) better describes a woman who
labor is next, and is characterized by apprehen- has had narcotic medications; some women
sion and anxiety; the patient becomes more in- may behave this way between pushing efforts
troverted, less social, and is focused on breath- during second stage. Quiet and concentrating
ing and pain relief. These phases all take place on contractions (3) describes a woman in active
during the first stage of labor, called dilation phase of first stage. Frustrated and losing con-
and effacement. The second stage is expulsion of trol (4) describes a woman in transition phase
the fetus, and the third stage is expulsion of the of first stage.
placenta (4). 14. Answer: 4
8. Answer: 2 Rationale: The cloudy yellow appearance of
Rationale: These signs suggest that the moth- the amniotic fluid suggests infection. The nurse
ers bladder is full (2), which can inhibit uter- should assess the womans temperature and
ine contraction that controls blood loss. The the fetal heart rate (4), which are typically el-
stem indicates that the uterus is firm, so mas- evated if infection is present. Removing wet
sage is not helpful (1). Analgesia (3) is not indi- underpads (1) is a comfort measure but not the
cated for this problem unless the woman also priority. Nothing suggests the need for vaginal
has pain (not stated in the stem). Oral intake is exam (2). Reassurance (3) is reasonable if other
usually encouraged, not restricted (4), both for signs are normal (such as FHR), but is not the
comfort and to maintain adequate urine output priority, or most important.
to flush organisms that could cause infection
from the bladder.

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15. Answer: 2 during labor. Bonding (4) is an important ob-
Rationale: Vaginal examinations can carry or-
ganisms from the nonsterile vagina upward
to the uterus, increasing the risk of infection
(2), particularly after the membranes rupture.
Vaginal examinations are usually somewhat
uncomfortable (1), but this is not the primary
reason to limit them. Vaginal exams do not
reduce FHR (3), nor do they delay progression
(4).
16. Answer: 1 Rationale: It is not possible to determine
Rationale: Birth can occur unexpectedly, es-
pecially during the second stage, so the nurse
should observe the womans perineum (1) in
addition to other labor care. Encouraging push-
ing with contractions (2) and evaluating labor
coping skills (3) are valid second stage inter-
ventions, but are not the priority. Analgesia (4)
is less frequently given this late.
17. Answer: 4
Rationale: The supine position (4) allows the
heavy uterus to compress the mothers large
blood vessels, reducing circulation to the pla-
centa and oxygen to the fetus. All other posi-
tions are appropriate (1, 2, 3), although walk-
ing cannot be done if regional blocks reduce
strength, movement, and sensation of the legs;
many facilities do not allow ambulation with
epidural of any type.
18. Answer: 2 blue-green, not solid green (2) or purple (4).
Rationale: Although not a common complica-
tion, a woman having a VBAC is slightly more
likely to have a ruptured uterus (2). Labor
progression is assessed in any woman (1). Peri-
neal pressure (3) is normal, suggesting onset of
the second stage. The nurse would be alert to
excess anxiety in any woman (4), not just one
having VBAC.
19. Answer: 4
Rationale: Persistent contractions at intervals
closer than 2 minutes (4) can reduce fetal oxy-
gen supply. Steps should be taken to reduce
their duration, such as discontinuing oxytocin
or giving a tocolytic drug. Clear amniotic fluid
with white specks, FHR of 145 BPM (1 and 2)
are normal, as is bloody show, which is thick
mucus mixed with pink or dark-brown blood
(3).
20. Answer: 1 of lochia are the principal observations (2).
Rationale: Hemorrhage (1) related to relaxation
of the uterus is the main risk after birth, both
vaginal and cesarean. Perineal bulging (2) de-
scribes fetal descent, just before crowning. In-
fection (3) can first be manifested during fourth
stage, but it is not the most immediate risk and
usually manifests later during the postpartum
period if the woman did not have infection
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Study Guide Answer Key Chapter 63
servation, but not the priority.
21. Answer: 2
Rationale: The uterus can be indented, al-
though not easily, in a moderate contraction
(2). It feels like the chin. Mild contractions (1)
are easily indented. Firm contractions (3) are
difficult to indent. Latent (4) is a phase of labor,
not contraction intensity.
22. Answer: 3
whether the membranes are ruptured by talk-
ing to the woman on the phone (3). It is some-
times difficult, even in person. If not in labor, a
woman at term who has ruptured membranes
may begin labor soon; however, she should
still be evaluated (1) for fetal cord compression
that may occur with membrane rupture. Also
the physician may induce labor. Urine leakage
(2) often does mimic membrane rupture, but a
pH, fern, or other test may help distinguish the
fluid source. Although there may be no con-
cern with clear fluid (4), the woman still needs
evaluation by an expert.
23. Answer: 3
Rationale: Evaluation of the alkalinity that
characterizes amniotic fluid is done with a pH
swab or paper (Nitrazine). Alkaline amniotic
fluid turns the swab or paper dark blue (3) or
Yellow (1) is the color of the paper or swab be-
fore it is dipped into the fluid and suggests that
membranes are intact.
24. Answer: 2
Rationale: Variable decelerations are often
caused by cord compression. Changing the
mothers position (2) may reduce pressure on
the cord. These decelerations are not expected
(1). Increasing plain IV fluid (3) is primarily a
response to late decelerations. The physician
should be notified as soon as possible (4), but
it is important to first relieve pressure on the
cord.
25. Answer: 2
Rationale: Relaxation of the uterus after birth
is the most common cause of hemorrhage.
Palpating for the firm fundus that compresses
bleeding vessels and observing the character
Assessing the blood pressure (1) identifies
hypotensive shock, but this added complica-
tion may be prevented by regular assessment
of the uterine fundus and vaginal bleeding.
An ice pack (3) is primarily for comfort and to
limit edema and perineal hematoma formation.
Urination (4) is important to prevent uterine
relaxation, but it does not substitute for proper
assessment of the lochia and fundus.
4Study Guide Answer Key Chapter 6

26. Answer: 2 by observing and making suggestions. Assess

Rationale: Placing the infant skin-to-skin with her for discomforts such as a full bladder and
the mother or other family member transmits help her walk to the bathroom or catheterize
heat and avoids loss of temperature (2). Breast- if ordered. Encourage her to change positions
feeding and early attachment (1 and 3) are de- about every 30 minutes and to sit or walk at
sirable, but retention of heat is the most critical intervals if desired and if medication does not
at this time. The placenta has most likely been interfere with safety. Squatting may be help-
expelled at this time (4). ful for pain and may help fetal descent. If back
pain is a factor, teach her support person meth-
ods such back massage and teach the woman
Crossword Puzzle to tell staff and support people what areas are
not comfortable. Teach or enhance relaxation
1
T techniques such as breathing and help the
H woman to reduce excessively high breathing
F L E X I ON DESCENT
2 3 4 5
rates. Reducing pain during labor is an ongo-
I X R U L ing process and this woman is well into active
R P D R E
S U A 6
A T T 7I T U 8D E labor, a time when many changes may be need-
T L 9 T R N E ed. Encourage the woman each time a positive
S I NT ENSI T Y F C effect of her labor is noted. Offer pharmaceuti-
I N O E R cal pain management as indicated.
OUT L E T
10 11
N C E
N E R T M
F RE QUE NCY
12
I N L E T 14
13

N E O N P Thinking Critically
A P RE S E NT AT I ON
15
1. a. Becky, Cathy, and Deanna
LI E S
16 17

X T b. Cathys and Deannas fetuses

S T AT I ON
18 19
E c. Deanna; this is her second baby, her cervix
E N R is completely dilated, and the fetus is low
R C I in her pelvis at a +2 station
N R O
A E F F A C E ME N T
20 21
R 2. a. 9
L 22 M I23 b. 9
V E RNI X DI L AT I ON E
24
c. 3
N P X d. 8
P OS I T I ON E N G A G E ME N T
25 26 27 28
e. 7
E E L N E
A C V T F
29
N f. 4
K O 30
I NT ERVAL S 3. A full bladder interferes with the contraction of
N S R L I the uterus, which is necessary to control blood
D I S O loss after birth.
O E N 4. a. Variability: reassuring of fetal health; may
R
be depressed by maternal analgesia
b. Accelerations: suggest that fetus is well-
Case Studies
oxygenated
1. A translator may be needed, and the clinic may
c. Early decelerations: fetal head compres-
have a phone line or other source for various
sion, reassuring but continue to observe for
languages if a person is not available to trans-
change
late. It is important to have a translator who is
d. Variable decelerations: suggest fetal cord
not related to the patient to ensure that critical
compression; reposition mother
information is communicated accurately. This
e. Late decelerations: suggest that placenta
woman had average length labors for her pre-
cannot supply sufficient oxygenated blood
vious babies, so should go to the birth facility
to the placenta; reposition, give oxygen, in-
when contractions are about 10 minutes apart.
crease rate of plain IV, stop oxytocin, and/
She should go if her water breaks whether
or give tocolytic if ordered
she is having contractions or not, for bleeding
other than bloody show with its mucus compo-
nent, if the baby is not moving as usual, or for
any other concern. The student should give an Applying Knowledge
individual rationale for chosen interventions. Answers will vary.
2. The progress appears normal for this woman.
Find ways to encourage her rest and relaxation

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