Chapter 16: Labor and Birth Processes
MULTIPLE CHOICE
1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. What is
the nurse’s best response, based upon her understanding of when the anterior frontal closes?
a. 2 months
b. 8 months
c. 12 months
d. 18 months
ANS: D
The larger of the two fontanels, 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.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. 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 NURSINGTB.COM
d. Position
ANS: 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.
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. 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
ANS: C
, Fetal 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.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. 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.”
N R I G B.C M
ANS: C U S N T O
Regular, 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.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
5. 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.
ANS: 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.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment | Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
6. 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
ANS: 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 progesteron NU RSelsIN
e lev .WGT B.
hen the O
fetus descends into the true pelvis (called
lightening), the fundal height may decrease. Urinary frequency may return before labor.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. Which stage of labor varies the most in length?
a. First
b. Second
c. Third
d. Fourth
ANS: 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.
MULTIPLE CHOICE
1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. What is
the nurse’s best response, based upon her understanding of when the anterior frontal closes?
a. 2 months
b. 8 months
c. 12 months
d. 18 months
ANS: D
The larger of the two fontanels, 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.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. 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 NURSINGTB.COM
d. Position
ANS: 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.
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. 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
ANS: C
, Fetal 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.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. 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.”
N R I G B.C M
ANS: C U S N T O
Regular, 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.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
5. 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.
ANS: 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.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment | Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
6. 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
ANS: 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 progesteron NU RSelsIN
e lev .WGT B.
hen the O
fetus descends into the true pelvis (called
lightening), the fundal height may decrease. Urinary frequency may return before labor.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. Which stage of labor varies the most in length?
a. First
b. Second
c. Third
d. Fourth
ANS: 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.
