Download CCTC NUR 220 UNIT 2 AND 3 (TEST 2) Questions with Complete Solutions | A+ Grade 2025-2026 and more Exams Nursing in PDF only on Docsity!
CCTC NUR 220 UNIT 2 AND 3 (TEST 2)
Questions with Complete Solutions | A+ Grade
Cervical Dilatation- - ✔✔widening of the cervical os and canal from less than 1 cm to 10 cm allowing birth of baby
Cervical Effacement- - ✔✔the taking up of the internal os and the cervical canal into the uterine side walls - 0% - 100%
Contractions- - ✔✔rhythmic tightening and shortening of the uterine muscles
Duration- - ✔✔-length of time from the beginning of one contraction to the completion of the same contraction
-how long that one contraction lasts
Frequency- - ✔✔time between the beginning of one contraction to the beginning of the next
Intensity- - ✔✔strength of the uterine contraction during acme (peak)
Accelerations- - ✔✔periodic increases in the baseline FHR (15 beats lasting for 15 secs)
Deceleration- - ✔✔decreases in FHR below the baseline
presenting part- - ✔✔portion of the fetus felt through the cervix on exam
Station- - ✔✔relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis (narrowest point is 0)
Engagement- - ✔✔occurs when the largest diameter of the presenting part reaches or passes through the pelvic inlet. Engagement confirms the adequacy of the pelvic inlet. It does not indicate whether the midpelvis and outlet are adequate
Fetal lie- - ✔✔relationship of the long (spinal column) axis of the fetus to the long axis of the mother
Critical Factors that Influence Labor: - ✔✔1. Passageway (mom's vagina, pelvis)
- Passenger (Fetus)
- Presentation (Relationship between passage and fetus)
- Powers of labor - physiologic forces
- Psychosocial considerations (what mom and fetus is going through)
Factors in labor: Components to look at with the birth passage: - ✔✔-Size of maternal pelvis
-Type of maternal pelvis
-Ability of the cervix to dilate and efface
Gynecoid pelvis: - ✔✔inlet rounded with all inlet diameters adequate, favorable for vaginal delivery. Most common, 50%. (best one)
Platypelliod Pelvis: - ✔✔inlet oval in shape with long transverse diameters, not favorable for birth. Head engages in transverse position. Delay of progress at outlet of pelvis. 5%
Android Pelvis: - ✔✔heart-shaped inlet with short posterior sagital diameter, not favorable for delivery. Head enters pelvis in transverse or posterior position and stops. Same as in males. 20%. Forceps are usually required with extensive perineal lacerations.
Anthropoid Pelvis: - ✔✔inlet oval in shape with long anteroposterior diameter, favorable for birth. 25%
Factors in labor: Components to look at with the Passenger: - ✔✔-Fetal Head (size and presence of molding)
-Fetal Attitude (flexion or extension of the fetal body and extremities)
posterior fontanelle- - ✔✔intersection b/t posterior cranial sutures
fetal attitude - ✔✔refers to the relationship of the fetal parts to one another
Normal fetal attitude- - ✔✔moderate flexion of the head so that chin is on the chest, flexion of the arm onto the chest, and flexion of the legs at the knee onto the abdomen.
Fetal lie- - ✔✔refers to the relationship of the cephalocaudal axis (spinal column) of the fetus to the cephalocaudal axis of the woman
longitudinal fetal lie- - ✔✔occurs when the cephalocaudal axis of the fetus is parallel to the woman's spine
transverse fetal lie- - ✔✔occurs when the cephalocaudal axis of the fetus is at a right angle to the woman's spine
Fetal presentation- - ✔✔Determined by fetal lie and by the body part of the fetus that enters the pelvic passage first called the presenting part.
Cephalic presentation- - ✔✔fetal head presents first
breech presentation - ✔✔when the baby's buttocks and/or feet appear first during birth
Complete breech- - ✔✔hips and knees flexed; the thighs are on the abdomen, and the calves are on the posterior aspects of the thighs; the buttocks and feet of the fetus present to the maternal pelvis.
Frank Breech- - ✔✔The Fetal hips are flexed, and the knees are extended; the buttocks of the fetus present to the maternal pelvis.
Footling breech- - ✔✔The fetal hips and legs are extended, and the feet of the fetus present to the maternal pelvis
Narrowest diameter of the pelvis the fetus must pass through: - ✔✔ischial spines
Where is the zero station? - ✔✔ischial spine
Fetal position- - ✔✔refers to the relationship of a designated landmark on the presenting fetal part to the front, back, or sides of the maternal pelvis
three notations used to describes fetal position: - ✔✔1. right (R) or left (L) side of the maternal pelvis
- The landmark of the fetal presenting part: Occiput (O), mentum (M), sacrum (S), or acromion process (A)
- Anterior (A), posterior (P), or transverse (T), depending on whether the landmark is in the front, back, or side of the pelvis.
Landmarks for fetal position: - ✔✔Landmark for vertex is occiput
Landmark for face is mentum
Landmark for breech is sacrum
Landmark for shoulder is acromion process on scapula
Engagement can be determines by: - ✔✔vaginal exam
When does engagement occur with primigravidas? and Multiparas? - ✔✔Primigravidas- approximately 2 weeks before term
Multiparas- may occur several weeks before the onset of labor or during the process of labor.
Ballotable- - ✔✔When the presenting part is not engaged it is said to be floating
Primary forces of labor- - ✔✔uterine muscular contractions, which cause the complete effacement and dilation of the cervix
Possible causes of labor: Corticotropin-Releasing Hormone Hypothesis- - ✔✔CRH increases throughout pregnancy with a sharp increase at term. May play a role in increased risk for preterm birth, and CRH levels are elevated in multiple gestations. Known to stimulate prostaglandin F and E by amnion cells.
Hormonal changes during labor: - ✔✔-↑Estrogen, ↑ Oxytocin, ↑ Prostaglandins
- ↑ Corticotropin-Releasing Hormone
- ↑ Hyaluronic acid which loosely binds collagen fibrils and a ↓ in dermatan sulfate which tightly binds collagen fibrils
- ↑ water content of cervix
- ↓Progesterone
- Fetus: ↑ cortisol
What happens to the muscle of the upper uterine segment during true labor? - ✔✔they shorten and exert a longitudinal pull on the cervix with each contraction, causing effacement. The cervix changes from a long, thick structure to one that is tissue paper thin.
Effacement- - ✔✔the drawing up of the internal os and the cervical canal into the uterine side walls. Goes from 1%-100%
When do primigravidas usually efface? - ✔✔before dilation
What happens as the uterus elongates and decreases in horizontal diameter? - ✔✔The fetus straightens up, pressing the upper portion against the fundus and thrusting the presenting part down toward the lower uterine segment and the cervix. The pressure exerted by the fetus is called the fetal axis pressure. As the uterus elongates, the longitudinal muscle fibers are pulled upward over the presenting part. This action and the hydrostatic pressure of the fetal membranes cause cervical dilatation.
What happens with the musculature changes in the pelvic floor during labor?s - ✔✔the levator ani muscle and fascia of the pelvic floor draw the rectum and vagina upward and forward with each contraction, along the curve of the pelvic floor. Pressure from the head causes the perineal structure to decrease from 5 cm to 1 cm thick. The decreased blood supply causes anesthesia in the area. The anus everts and exposes the interior rectal wall.
Premonitory signs of labor: - ✔✔- Cervical changes
- Lightening
- Increased energy level
- "Bloody show"
- Braxton Hicks contractions
-Ruputure of membranes (SROM, PROM, PPROM)
-other signs such as weight loss of 1-3 lbs dt/ fluid loss and electrolyte shifts produced by changes in estrogen and progesterone levels, diarrhea, indigestion, or N/V
Lightening- - ✔✔-the sensation of the fetus moving from high in the abdomen to low in the birth canal
-pt will notice: leg cramps or pains d/t pressure on the nerves that pass through the obturator foramen in the pelvis; increased pelvic pressure; increased venous stasis, leading to edema in the lower extremities; increased vaginal secretions resulting from congestion of the vaginal mucous membranes.
Cervical changes during pregnancy: - ✔✔at the beginning of pregnancy, the cervix is rigid and firm, and it must soften so it can stretch and dilate to allow the fetus passage. The softening of the cervix is called ripening. As term approaches, collagen fibers in the cervix are broken down by certain enzymes. As the fibers change, their ability to bind together decreases, while the water content of the cervix increases. These changes result in a weakening and softening of the cervix.
Bloody show - ✔✔with softening and effacement the mucous plug is often expelled, resulting in a small amount of blood loss from the exposed cervical capillaries. This is considered a sign that labor will begin within 24-48 hours.
Women who are 34 weeks gestation or more who present with ruptured membranes w/out
contractions are often started on what? this prevents what? - ✔✔started on an oxytocin infusion to decrease the incidence of chorioamnionitis.
What is the risk if the membranes rupture and engagement has not occurred yet? - ✔✔there is a danger of the umbilical cord washing out with the fluid (prolapsed cord). Also increases the risk of infection.
Signs of True labor - ✔✔-contractions are regular with increasing frequency (shortened intervals), duration, and intensity
First Stage of Labor: Active Phase - ✔✔-anxiety tends to increase
-pt shows decreased ability to cope and a sense of helplessness
-cervix dilates from about 4-7 cm
-fetal descent is progessive.
-cervical dilatation averages 1.2 cm/hr in nulliparas and 1.5 cm/hr in multiparas
First stage of labor: Transition phase- - ✔✔-significant anxiety, restless, changing positions, may fear being left alone. Nurse should be there to support.
-dilation from 8-10 cm. fetal descent increases.
-contractions have a frequency of about every 1.5-2.0 min, a duration of 60-90 sec and strong intensity.
-does not last longer than 3 hours in nulliparas, 1 hour in multiparas. Time may be increased 1 hour with an epidural.
-contractions are more frequent, longer, and more intense. As you approach 10 cm there is increased rectal pressure (no going to the bathroom), increased bloody show, and ROM.
-May feel like their abdomen is going to burst. May doubt her ability to cope. May be terrified of being alone but does not want to be touched. Could have N/V, yelling, crying, sweating, hyperventilation. Anxious to get it over with.
Second Stage of labor: - ✔✔-usually last 2 hours of primipara, 15 min for multpara. Additional hour for epidural.
-contractions continue with a frequency of about every 1.5-2.0 minutes, duration 60 to 90 seconds. Fetus descends to perineal floor.
-Because of pressure the woman feels the urge to push. Perineum begins to bulge and push out. Bloody show increases.
-Crowning -head is encircled by the external opening of the vagina and means birth is imminent. Acute, increasing pain and burning sensation. May feel relief that she can now push. Those who are not prepared may feel frightened (story about women jumping around)
-Spontaneous birth- perineum becomes thin, anus stretches and protrudes. The head extends and goes under the symphysis pubis. A gentle push then delivers the shoulders.
-Cardinal Movements of labor
Second Stage of labor: latent/passive descent stage- - ✔✔Woman may initially experience the urge to push. Passive fetal descents occurs in response to the uterine contractions
Nursing Interventions: Assessing the woman's perception of the need/urge to push; evaluating the maternal-fetal oxygenation status to ensure adequate uteroplacental perfusion is occurring; assessing fetal status through recommended monitoring protocols.
Second stage of labor: active pushing phase- - ✔✔occurs once the urge to push has been established and the woman begins to actively push with her contractions.
Nursing interventions: assessing the effectiveness of the maternal pushing efforts; providing encouragement and direction to obtain a more adequate pushing effort; assessing fetal response that occurs as maternal pushing is performed, including continued fetal assessment measures.
Cardinal Movement of labor - ✔✔1. Descent- because of 4 forces. Pressure of amniotic fluid, pressure of fundus on the breech , contraction of abdominal muscles, extension and straightening of fetal body. Head enters in the occiput transverse or oblique position.
- Flexion-fetal head descends and meets resistance so the chin flexes downward onto the chest.
- Internal rotation- head rotates to fit the diameter of the pelvic cavity. As the occiput of the fetal head meets resistance from the levator ani muscles and their fascia the occiput rotates left to right and the sagittal suture aligns in the anteroposterior pelvic diameter.
- Extension- head extends as it passes under the symphysis pubis. The occiput, brow, and face emerge.
- Restitution- the shoulders of the fetus enter the pelvic inlet obliquely and remain oblique when the head rotates to the anteroposterior diameter through internal rotation causing a twisted neck. Neck will untwist at birth of the head
- External rotation- as shoulders rotate to the anteroposterior position in the pelvis, the head turns farther to one side.
- Expulsion- through mom's pushing efforts, the anterior shoulder meets the surface of the symphysis pubis and slips under it. As lateral flexion of the shoulder and head occurs, the anterior shoulder is born before the posterior should. The body follows quickly.
3rd Stage of labor: - ✔✔-placental separation
-delivery of placenta: woman may bear down to aid expulsion. If the fundus is firm gentle pressure can be applied to the cord while pressing on the fundus. A retained placenta is one that does not come out after 30 min. Fetal side (shiny) may be outside or maternal side (rough). Look to see what side deliver first.
-lasts about 5-30 min
Signs the placenta is ready to deliver - ✔✔1. a globular-shaped uterus (ovular)
-With hyperventilation there is a decrease in PaCO2 leading to respiratory alkalosis. Levels balance within 24 hours after birth.
-By the end of the first stage, most women have developed metabolic acidosis compensated by respiratory alkalosis. As the push in the second stage of labor, their PaCO2 levelsmay rise along with blood lactate levels and mild respiratory acidosis occurs. By the time the baby is born, the woman has metabolic acidosis uncompensated for by respiratory alkalosis. These changes are quickly reversed in the 4th stage b/c of changes in women's resp. rates.
Maternal Response to labor: renal system- - ✔✔-during labor there is an increase in maternal renin, plasma renin activity, and angiotensinogen. This elevation is thought ot be important in the control of uteroplacental blood flow during birth and the early postpartum period.
-Physically the bladder is pushed forward and upward possibly impairing blood and lymph drainage leading to edema of the tissues and possible trauma to the lower urinary tract causing hematuria
Maternal response to labor: GI- - ✔✔-during labor gastric motility and absorption of solid food are reduced.
-gastric emptying time is prolonged, and gastric volume remains increased (regardless of time of last meal)
-some narcotics delay gastric emptying and add to risk of aspiration if general anesthesia is used.
Maternal response to labor: Immune system and other blood values: - ✔✔-WBC increases to 25,000- 30,000 d/t stress.
-Maternal glucose levels decrease b/c body uses glucose as energy during contractions
causes of pain during labor: - ✔✔- 1st stage pain from 1. dilation of cervix (primary). 2 hypoxia of uterine muscle cells during ctx 3. stretching of lower uterine segment 4. pressure on adjacent structure
- 2nd stage pain- 1. hypoxia of the contracting uterine muscle cells 2.distention of the vagina and perineum 3. pressure on adjacent structures like lower back, buttocks, and thighs
- 3rd stage- pain from ctx and dilation as placenta is expelled. Anesthesia may be needed for episiotomy repair.
Factor affecting response to pain during labor: - ✔✔-culture
-fatigue and sleep deprivation influence response to pain
-previous experience w/ pain and her anxiety level
-unfamiliar surroundings and events can increase anxiety, as does separation from family and loved ones.
-anticipation of discomfort and questions about whether she can cope can increase anxiety.
-attention and distraction influence the perception of pain
Fetal responses to labor: Heart rate changes - ✔✔-FHR decelerations can occur with intracranial pressures of 40-55, as head pushes against the cervix.
-early deceleration is believed to be d/t hypoxic depression of the CNS, which is under vagal control
fetal responses to labor: acid-base status - ✔✔blood flow to fetus is slowed at the peak of ctx causing a slow decrease in PH. Stronger and longer ctx cause a fast decrease in PH as well as O2 sat. If it continues it can cause organ dysfunction and neuro impairment.
Fetal response to labor: Hemodynamic changes- - ✔✔-decreased blood flow
-fetal blood pressure helps to ensure the right exchange of nutrients and gases to help the fetus through anoxic periods.
Fetal response to labor: behavioral states- - ✔✔Sleep and active states develop between 36 and 38 weeks so there may be periods of decreased variability and fetal breathing movements.
Fetal response during labor: Fetal sensation- - ✔✔-At 37-38 weeks the fetus senses light, sound, and touch.
-full term fetus able to hear music and maternal voice.
-term baby is aware of pressure sensations during labor such as touch of HCP during a vaginal exam or pressure on the head as contraction occurs
Intrapartum assessment - ✔✔-Vital signs/Weight
-Allergies, medications
-Time last ate, drank
-Lung sounds
fetal presentation
before performing Leopold's Maneuvers Nursing interventions: - ✔✔-have pt void
-have pt lie on her back with feet on the bed and her knees bent.
External electric monitoring of the contractions: - ✔✔The portion of the monitoring equipment that monitors the contractions is called a tocodynamometer or Toco, is positioned against the uterine fundus and held in place w/ an elastic belt. This tells the frequency and duration of contractions. The lower belt holds the ultrasonic device that monitors the FHR. The fetal monitor must be placed on the fetuses back.
Intrauterine Pressure Catheter (IUPC) - ✔✔the spiral electrode is inserted into the uterine cavity. Done after ROM, 2 cm dilated, the presenting part is down against the cervix, and the presenting part is known. Better for VBAC because of exact measurements. Invasive, increases risk of infection, not with low lying placenta. Has to be inserted properly.
Auscultation of FHR with handheld doppler ultrasound: - ✔✔used to auscultate FHR b/t, during, and immediately after uterine contractions
Auscultation of FHR with fetoscopes: - ✔✔can be used to auscultate the FHR after 20 weeks.
If fetus is in cephalic presentation, the FHR would best be heard where? Breech presentation?
Transverse lie presentation? - ✔✔Cephalic presentation: FHR heard in the lower quadrant of moms abdomen
Breech presentation: FHR heard at or above the level of the maternal umbilicus
Transverse Lie: FHR heard just above or just below the umbilicus.
Indications for Electronic Fetal monitoring: - ✔✔-previous history of stillbirth at 38+ wks
-complication of pregnancy is present
-induction of labor
-preterm labor (less than 37 weeks completed)
-decreased fetal movement
-non-reassuring fetal status
-meconium staining
-Trial Of Labor After C-Section
How to avoid mixing up the Moms HR with the FHR while using an electronic monitor? - ✔✔By palpating the maternal pulse or using a pulse Ox to compare to the rate of the FHR.
Normal FHR: - ✔✔110-160 bpm
When should internal fetal monitoring be avoided? - ✔✔With HIV, Hep B, GBS, premature (IVH)
Most common cause of late decelerations: - ✔✔maternal hypotension resulting from the admin. of epidural anesthesia and uterine tachysystole associated w/ oxytocin infusion
Indications for cord blood analysis: - ✔✔-meconium stained amniotic fluid
-significantly abnormal FHR patterns
-newborn is depressed at birth
-apgar scores are less than 7 at 5 minutes of age.
What does cord blood analysis determine? - ✔✔Tells whether acidosis is due to hypoperfusion of the placenta or to cord compression.
How is cord blood analysis performed? - ✔✔the cord is clamped before the baby takes the first breath. A small amount of blood is aspirated w/ a syringe from one of the umbilical arteries. If the cord blood will not be analyzed immediately, a heparinized syringe should be used. Normal fetal blood pH should be above 7.25. Lower levels indicated acidosis and hypoxia
Lamaze- - ✔✔(psychoprophylactic) Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process
date and time of arrival and notification of the HCP
the condition of the woman and her baby
labor and membrane status
Maternal and fetal assessment during First stage of labor: - ✔✔Maternal: BP, resp each hour if in normal range
Fetal: FHR Q30M for low risk women and Q15M for high risk women. Note fetal activity. If electronic fetal monitor is in place, assess for reactive non-stress test
Maternal and fetal assessment during Latent Phase: - ✔✔Maternal: temp Q4H unless over 99.6F (37.5C) or membranes ruptured, then Qhour. Uterine contractions Q30M.
Fetal: FHR Q30M for low risk women and Q15M for high risk women. Note fetal activity. If electronic fetal monitor is in place, assess for reactive non-stress test
Maternal and fetal assessment during Active phase: - ✔✔Maternal: BP, Pulse, resp Qhour if in normal range. Uterine contractions palpated Q15-30M
Fetal: FHR Q30M for low risk women and Q15M for high risk women
Maternal and fetal assessment during transition phase: - ✔✔maternal: BP, pulse, resp. Q30M. Contractions palpated at least Q15M
Fetal: FHR Q30M for low risk women and Q15M for high risk women
Maternal and fetal assessment during Second Stage of labor: - ✔✔Maternal: BP, pulse, resp. Q5-15M. Temp. Q2H. Uterine contractions palpated continuously
Fetal: FHR Q15M for low risk women and Q5M for high risk women
Maternal and fetal assessment during 3rd stage of labor: - ✔✔maternal: BP, pulse, resp Q5M. Palpate uterine contractions intermittently to assess for signs of placenta separation
Fetal: Newborn assessment at time of birth, gestational age assessment, and neurologic assessment w/in first hour of birth. Apgars at 1 and 5 min. Assess initial BP, apical pulse, resp., and temp. Assess umbilical cord for the presence of three vessels
Maternal and fetal assessment during fourth stage of labor: - ✔✔maternal: assess maternal VS including temp., BP, pulse, and resp Q5-15min for first hour. Assess fundus, lochia, perineum, laceration/episiotomy site, bladder distention, and rectum Q15M
Fetal: perform complete exam to include VS, gestational age assessment, physical exam, and neurologic reflexes once b/t 1 and 4 hour postbirth. After initial 8 hr, assess VS and perform assessment Q8H. Skin color should be assessed Q4H
Promoting comfort in first stage of labor: - ✔✔-pattern of coping ranges from the use of highly structure breathing techniques to turning inward.
-low moaning, rocking, facial grimace, using loud vocalizations
-a woman usually wants touching, massage, effleurage, and other forms of physical contact during first part of labor but may not want this during transition phase
-massage, hydrotherapy, position changes, hypnosis, aromatherapy, sitting in rocking chair, walking, leaning against something, use of TENS unit, relaxation techniques, prayer/meditation, breathing techniques, acupressure
-fresh dry bed linen
-Encourage pt to empty bladder Q1-2H
-Give pt information to relieve anxiety
-establish rapport
-express confidence in couple's ability to work with the labor process
Assisting with delivery: - ✔✔-Birthing position
-Cleaning the perineum
-labor support: nurse encourages pt to pant to prevent pushing when the head emerges. HCP checks babys head to make sure umbilical cord is around the neck, suctions the mouth and nose with bulb syringe. Mouth is suctioned first to prevent reflex inhalation of mucus when the nostrils are touched with the bulb syringe tip. Woman encouraged to push again to birth the fetus body.
-DON'T RAISE BABY UP BEFORE CLAMPING THE UMBILICAL CORD BECAUSE THE BLOOD WILL GO BACK INTO THE MOM
Initial care of the newborn: - ✔✔-place newborn on moms abdomen
-newborn maintained in a modified trendelenburg position. Gravity will aid drainage of mucus from the nasopharynx and trachea
