Chapter 08: Nursing Care of Women with Complications During Labor and Birth Nursing School Test Banks

Chapter 08: Nursing Care of Women with Complications During Labor and Birth

MULTIPLE CHOICE

1. What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. Maternal temperature is 37.8 C.
ANS: C
Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.

DIF: Cognitive Level: Application REF: Page 176 OBJ: 3
TOP: Obstetric ProceduresAmniotomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

2. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurses initial action?
a. Stop the oxytocin infusion.
b. Continue the infusion and report the findings to the physician.
c. Turn her on her left side and reassess the contractions.
d. Administer oxygen by mask.
ANS: A
Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

DIF: Cognitive Level: Application REF: Page 177 OBJ: 3
TOP: Obstetric ProceduresInduction of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

3. What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
a. Warm compresses to the perineum
b. Cold pack to the perineum
c. Warm sitz bath
d. Elevation of hips to prevent edema
ANS: B
Ice is applied to the perineum to reduce bruising and edema.

DIF: Cognitive Level: Application REF: Page 180 OBJ: 3
TOP: Obstetric ProceduresLacerations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered?
a. Normal
b. Hypotonic
c. Hypertonic
d. False
ANS: B
The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.

DIF: Cognitive Level: Comprehension REF: Page 187, Box 8-2
OBJ: 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. What action by the physician will the nurse anticipate?
a. Perform an amniotomy.
b. Initiate tocolytic drugs.
c. Order a sedative for the patient.
d. Plan to do an emergency cesarean section.
ANS: A
Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact.

DIF: Cognitive Level: Comprehension REF: Page 176, 187
OBJ: 2 | 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

6. An infant is delivered with the use of forceps. What should the nurse assess for in the newborn?
a. Loss of hair from contact with forceps
b. Sacral hematoma
c. Facial asymmetry
d. Shoulder dislocation
ANS: C
Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry.

DIF: Cognitive Level: Application REF: Page 181 OBJ: 3
TOP: Obstetric ProceduresForceps Delivery
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The nurse responds, This condition will resolve itself in a few days. What is the cause?
a. Prolonged pressure against the partially dilated cervix
b. Small leak of fluid through the posterior fontanelle
c. Pressure of the forceps during delivery
d. The effect of the vacuum extractor
ANS: D
The chignon is due to the effect of the vacuum extractor and will disappear in a few days.

DIF: Cognitive Level: Comprehension REF: Page 181 OBJ: 2
TOP: Chignon KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the lowest Bishop score the patient should have prior to induction?
a. 6
b. 8
c. 10
d. 12
ANS: A
The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG).

DIF: Cognitive Level: Comprehension REF: Page 175, Table 8-1
OBJ: 2 TOP: Bishop Scoring for Vaginal Delivery
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

9. A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief?
a. Prone with legs supported and give her a back massage
b. Supine with legs bent at the knee
c. Standing with support
d. Sitting up and leaning forward on the over-bed table
ANS: D
A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.

DIF: Cognitive Level: Application REF: Page 189-190
OBJ: 7 TOP: Abnormal Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance

10. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor?
a. Get an order for an intravenous narcotic.
b. Notify the anesthesiologist for an epidural block.
c. Stay and breathe with her during contractions.
d. Tell her to bear with it because she is close to delivery.
ANS: C
The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.

DIF: Cognitive Level: Application REF: Page 191-192
OBJ: 6 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

11. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient?
a. Chorioamnionitis
b. Hemorrhage
c. Hypotension
d. Amniotic fluid embolism
ANS: A
Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.

DIF: Cognitive Level: Application REF: Page 192 OBJ: 5
TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

12. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect?
a. Maternal tachycardia
b. Maternal hypertension
c. Fetal bradycardia
d. Fetal hypokalemia
ANS: A
Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol.

DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6
TOP: Preterm Labor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

13. Which statement indicates a woman understands activity limitations for the management of preterm labor?
a. After my shower in the morning, I do the laundry and straighten up the house; then I rest.
b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.
c. I have a 2-year-old to care for, but I try to rest as much as I can.
d. I get really bored at home, so I go to the shopping mall for just a little while.
ANS: B
Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

DIF: Cognitive Level: Comprehension REF: Page 194 OBJ: 5
TOP: Preterm Labor KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

14. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response?
a. The fundus is not assessed until the second postoperative day.
b. The fundus is assessed by walking fingers from the side of the uterus to the midline.
c. The fundus is assessed only if large clots appear in lochia.
d. The fundus is assessed only once every shift.
ANS: B
Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.

DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4
TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord?
a. On her right side with knees flexed
b. On her left side with a pillow placed between her legs
c. On her back with her head lower than the rest of her body
d. Supine with her legs elevated and bent at the knee
ANS: C
The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.

DIF: Cognitive Level: Application REF: Page 195 OBJ: 8
TOP: Emergencies During ChildbirthProlapsed Umbilical Cord
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

16. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis?
a. Anxiety related to the development of postpartum complications
b. Ineffective individual coping related to unfamiliarity with procedures
c. Risk for ineffective parenting related to emergency cesarean section
d. Grieving related to loss of expected birth experience
ANS: D
Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.

DIF: Cognitive Level: Application REF: Page 183 OBJ: 8
TOP: Cesarean Section KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

17. A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do?
a. Report any increase in fetal activity.
b. Notify her obstetrician if she has a temperature above 37.8 C (100 F).
c. Massage her breasts to promote uterine relaxation.
d. Rest in a side-lying Trendelenburg position with hips elevated.
ANS: B
For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F).

DIF: Cognitive Level: Application REF: Page 192 OBJ: 6
TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk

18. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience?
a. Nausea and vomiting
b. Headache
c. Warm flush
d. Urinary frequency
ANS: C
Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

DIF: Cognitive Level: Knowledge REF: Page 193 OBJ: 6
TOP: Preterm Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

19. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor?
a. By decreasing a womans pain sensitivity
b. By reducing blood flow to the uterus
c. By increasing the ability to tolerate pain
d. By enhancing maternal pushing through greater muscle tension
ANS: B
Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

DIF: Cognitive Level: Comprehension REF: Page 191 OBJ: 2
TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance

20. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action?
a. Give the pain remedy.
b. Notify the charge nurse immediately.
c. Turn the patient to her back and flex her knees.
d. Suggest that the coach give her a back rub.
ANS: B
Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.

DIF: Cognitive Level: Application REF: Page 195 OBJ: 3
TOP: Uterine Rupture KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

21. What does the nurse explain is used to soften the cervix with a cervical ripening agent?
a. Prostaglandin gel insertion
b. Intravenous oxytocin
c. Warm saline douches
d. Nipple stimulation
ANS: A
Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.

DIF: Cognitive Level: Knowledge REF: Page 175 OBJ: 3
TOP: Cervical Ripening KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

22. The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration?
a. Prevent infection.
b. Increase fetal lung maturity.
c. Increase blood flow from placenta.
d. Relax the cervix.
ANS: B
Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6
TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

23. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first?
a. 18-year-old primigravida with a fetal breech presentation
b. 25-year-old multigravida with history of previous cesarean section
c. 35-year-old multigravida with history of precipitate birth
d. 16-year-old primigravida with a twin pregnancy
ANS: C
A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth.

DIF: Cognitive Level: Analysis REF: Page 191 OBJ: 7
TOP: Precipitate Birth KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

24. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient?
a. Elevated uterine resting tone
b. Painful and poorly coordinated contractions
c. Implementation of fluid restriction
d. Use of frequent position changes
ANS: D
A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor.

DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6
TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

25. What sign(s) of infection should the nurse assess for after an amniotomy? (Select all that apply.)
a. Oral temperature of 37 C (99.8 F)
b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute
c. Flecks of vernix in the amniotic fluid
d. Low back pain
e. Edematous labia
ANS: B
Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation. All the other options are normal findings for late pregnancy.

DIF: Cognitive Level: Application REF: Page 176 OBJ: 3
TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

26. What are the rationales for labor induction? (Select all that apply.)
a. Placenta previa
b. Prolapse of cord
c. High station of fetus
d. Maternal diabetes
e. Placental insufficiency
ANS: D, E
Maternal diabetes and placental insufficiency are rationales for induction. The other options are contraindications for labor induction.

DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2
TOP: Rationales for Labor Induction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

27. Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.)
a. Encouraging the patient to sit upright
b. Assisting the patient to ambulate
c. Stimulating the nipples
d. Offering emotional support
e. Allowing the patient to vent frustration
ANS: A, B, C
Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor.

DIF: Cognitive Level: Application REF: Page 177 OBJ: 3
TOP: Hypotonic Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

28. What complications of overstimulation of uterine contractions may occur? (Select all that apply.)
a. Water intoxication
b. Impaired placental exchange of oxygen and nutrients
c. Increased blood pressure
d. Convulsions
e. Uterine rupture
ANS: A, B, E
The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.

DIF: Cognitive Level: Comprehension REF: Page 178 OBJ: 6
TOP: Complication of Oxytocin KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.)
a. Place a warm, moist washcloth over the breast.
b. Brush the nipples with a dry washcloth.
c. Gently pull on the nipples.
d. Apply suction to the nipples with a breast pump.
e. Press the palms of her hands down on her breasts.
ANS: B, C, D
Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions.

DIF: Cognitive Level: Application REF: Page 177 OBJ: 5
TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What conditions would contraindicate labor induction? (Select all that apply.)
a. Maternal gynecoid pelvis
b. Placenta previa
c. Horizontal cesarean incision
d. Prolapsed cord
e. Gestational diabetes
ANS: B, D
Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. Gynecoid pelvis is the most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labor induction.

DIF: Cognitive Level: Comprehension REF: Page 175 OBJ: 2
TOP: Induction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

31. A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.)
a. Insert IV.
b. Record a baseline fetal heart rate.
c. Explain procedure to patient.
d. Instruct patient to ambulate immediately afterward.
e. Ensure a tocolytic is available.
ANS: A, B, C
The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.

DIF: Cognitive Level: Application REF: Page 175-176
OBJ: 3 TOP: Cervical Ripening
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

COMPLETION

32. After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________.

ANS:
amnioinfusion

A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord.

DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 3
TOP: Amnioinfusion KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

33. _____________________________ is a lower-than-normal amount of amniotic fluid.

ANS:
Oligohydramnios

Oligohydramnios is a lower amount than normal of amniotic fluid.

DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1
TOP: Amniotic Fluid KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Reduction of Risk

34. A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions.

ANS:
laminaria

A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water.

DIF: Cognitive Level: Knowledge REF: Page 176 OBJ: 1
TOP: Laminaria KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

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