1. A client reports that her contractions started about 1 hr ago and decreased after drinking two glasses of

water and walking. She reports the contractions occur every 10 to 15 min and that she hasn’t had anyfluid

leaking or vaginal bleeding. The nurse should recognize that the client is experiencing

A. Braxton Hicks contractions.

B. Rupture of membranes.

C. Fetal descent.

D. True contractions.

Braxton Hicks contractions decrease with hydration and walking. True contractions do not go away with hydration or

walking. Instead, they are regular in frequency, duration, and intensity, becoming stronger withwalking. Fetal descent is the

downward movement of the fetus in the birth canal. Rupture of membranes is when the amniotic membranes rupture and

allow the amniotic fluid to escape.

2. Identify and describe the three phases of the first stage of labor.

In stage 1, latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 sec. In stage 1,

active phase, the cervix dilates from 4 to 7 cm, and contraction duration ranges from 40 to 70 sec. In stage 1, transition

phase, the cervix dilates from 8 to 10 cm, and contraction duration ranges from45 to 90 sec.

3. While assisting the nurse with an admission history for a client at 39 weeks of gestation, the client tells

the nurse that water has been leaking from her vagina for 2 days. The nurse knows that this client is at

risk for

A. cord prolapse.

B. infection.

C. postpartum hemorrhage.

D. hydramnios.

Rupture of membranes exceeding 24 hr before delivery increases the risk that infectious organisms will

enter the vagina and then eventually into the uterus. While cord prolapse is a riskwith rupture of membranes,

it occurs when the fluid rushes out, rather than trickling or leaking out. The client is not at any greater risk for

postpartum hemorrhage than other clients who are pregnant. Hydramnios means excess amniotic fluid. The

client is more likely to have oligohydramnios or insufficient amniotic fluid.

4. A nurse is reinforcing non-pharmacologic pain interventions for lower back pain due to occiput

posterior presentation with a group of clients. Which of the following statements regarding nonpharmacologic interventions indicates the client understands an effective intervention for this type of

pain?

A. “Ishould use effleurage to alleviate the discomfort.”

B. “I will get my husband to apply sacral counter-pressure during labor.”

C. “I will try hydrotherapy during my labor to relieve the back pain.”

D. “Ishould use massage throughout my labor.”

Sacral counterpressure is the application of steady pressure to the lower back to counteract the pressure

exerted on the spinal nerves by the fetus, which especially occurs with an occiput posterior presentation.

Abdominal effleurage is a gentle stroking of the abdomen in rhythm withbreathing during contractions.

Hydrotherapy may be helpful, but counterpressure is the most effective in relieving back discomfort.

5. A nurse is assisting with the care of a primipara in active labor who received meperidine (Demerol) 50

mg IV bolus for pain 30 min prior to precipitous delivery. The nurse is aware that naloxone (Narcan) is to

be administered to the newborn for which of the following?