Chapter 16: Nursing Care of the Family during Labor and Birth Nursing School Test Banks

Chapter 16: Nursing Care of the Family during Labor and Birth

MULTIPLE CHOICE

1. The nurse recognizes that a woman is in true labor when she states:

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.

ANS: C

Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.

PTS: 1 DIF: Cognitive Level: Application REF: 402

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the womans understanding of the instructions when she states, True labor contractions will:

a.

Subside when I walk around.

b.

Cause discomfort over the top of my uterus.

c.

Continue and get stronger even if I relax and take a shower.

d.

Remain irregular but become stronger.

ANS: C

True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.

PTS: 1 DIF: Cognitive Level: Application REF: 402

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

3. When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:

a.

Tell the woman to stay home until her membranes rupture.

b.

Emphasize that food and fluid intake should stop.

c.

Arrange for the woman to come to the hospital for labor evaluation.

d.

Ask the woman to describe why she believes she is in labor.

ANS: D

Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin the assessment and gather data. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular. The nurse may want to discuss the appropriate oral intake for early labor such as light foods or clear liquids, depending on the preference of the client or her primary health care provider. Before instructing the woman to come to the hospital, the nurse should initiate the assessment during the telephone interview.

PTS: 1 DIF: Cognitive Level: Application REF: 402

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. What is an expected characteristic of amniotic fluid?

a.

Deep yellow color

b.

Pale, straw color with small white particles

c.

Acidic result on a Nitrazine test

d.

Absence of ferning

ANS: B

Amniotic fluid normally is a pale, straw-colored fluid that may contain white flecks of vernix. Yellow-stained fluid may indicate fetal hypoxia up to 36 hours before rupture of membranes, fetal hemolytic disease, or intrauterine infection. Amniotic fluid produces an alkaline result on a Nitrazine test. The presence of ferning is a positive indication of amniotic fluid.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 414

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the womans risk for _________________________ has increased.

a.

Intrauterine infection

c.

Precipitous labor

b.

Hemorrhage

d.

Supine hypotension

ANS: A

When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 414

OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

6. Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions?

a.

Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips.

b.

Determine the frequency by timing from the end of one contraction to the end of the next contraction.

c.

Evaluate the intensity by pressing the fingertips into the uterine fundus.

d.

Assess uterine contractions every 30 minutes throughout the first stage of labor.

ANS: C

The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus that may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses this assessment is performed more frequently.

PTS: 1 DIF: Cognitive Level: Application REF: 411

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

7. When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be:

a.

Dilation of the cervix.

c.

Rupture of the amniotic membranes.

b.

Descent of the fetus.

d.

Increase in bloody show.

ANS: A

The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor. Descent of the fetus, or engagement, may occur before labor. Rupture of membranes may occur with or without the presence of labor. Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 404

OBJ: Nursing Process: Assessment, Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

8. The nurse who performs vaginal examinations to assess a womans progress in labor should:

a.

Perform an examination at least once every hour during the active phase of labor.

b.

Perform the examination with the woman in the supine position.

c.

Wear two clean gloves for each examination.

d.

Discuss the findings with the woman and her partner.

ANS: D

The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.

PTS: 1 DIF: Cognitive Level: Application REF: 411

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

9. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurses initial response would be to:

a.

Prepare the woman for imminent birth.

b.

Notify the womans primary health care provider.

c.

Document the characteristics of the fluid.

d.

Assess the fetal heart rate and pattern.

ANS: D

The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed. The nurses priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.

PTS: 1 DIF: Cognitive Level: Application REF: 414

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. A nulliparous woman who has just begun the second stage of her labor would most likely:

a.

Experience a strong urge to bear down.

b.

Show perineal bulging.

c.

Feel tired yet relieved that the worst is over.

d.

Show an increase in bright red bloody show.

ANS: C

Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because the worst is over. During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 425

OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

11. The nurse knows that the second stage of labor, the descent phase, has begun when:

a.

The amniotic membranes rupture.

b.

The cervix cannot be felt during a vaginal examination.

c.

The woman experiences a strong urge to bear down.

d.

The presenting part is below the ischial spines.

ANS: C

During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 425

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

12. When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:

a.

Encouraging the woman to try various upright positions, including squatting and standing.

b.

Telling the woman to start pushing as soon as her cervix is fully dilated.

c.

Continuing an epidural anesthetic so pain is reduced and the woman can relax.

d.

Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

ANS: A

Upright positions and squatting both may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to labor down (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if the woman is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 426

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

13. Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as:

a.

First stage, latent phase.

c.

First stage, transition phase.

b.

First stage, active phase.

d.

Second stage, latent phase.

ANS: B

The first stage, active phase of maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress would be 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes. During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of laboring down.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 401

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

14. The most critical nursing action in caring for the newborn immediately after birth is:

a.

Keeping the newborns airway clear.

b.

Fostering parent-newborn attachment.

c.

Drying the newborn and wrapping the infant in a blanket.

d.

Administering eye drops and vitamin K.

ANS: A

The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-infant attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The nursing activities would be (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering the infant with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborns physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the infant to the partner or mother when he or she is ready.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 434

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

15. When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the womans fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that:

a.

The placenta has separated.

b.

A cervical tear occurred during the birth.

c.

The woman is beginning to hemorrhage.

d.

Clots have formed in the upper uterine segment.

ANS: A

Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 436

OBJ: Nursing Process: Assessment, Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

16. The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to:

a.

Relieve pain.

c.

Prevent infection.

b.

Stimulate uterine contraction.

d.

Facilitate rest and relaxation.

ANS: B

Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain or prevent infection. They cause the uterus to contract, which reduces blood loss. Oxytocics do not facilitate rest and relaxation.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 436

OBJ: Nursing Process: Planning, Implementation

MSC: Client Needs: Health Promotion and Maintenance

17. After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:

a.

Facilitate maternal-newborn interaction.

b.

Stimulate the uterus to contract.

c.

Prevent neonatal hypoglycemia.

d.

Initiate the lactation cycle.

ANS: B

Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin, which prevents hemorrhage. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 427

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

18. A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that true labor contractions:

a.

Increase with activity such as ambulation.

b.

Decrease with activity.

c.

Are always accompanied by the rupture of the bag of waters.

d.

Alternate between a regular and an irregular pattern.

ANS: A

True labor contractions become more intense with walking. False labor contractions often stop with walking or position changes. Rupture of membranes may occur before or during labor. True labor contractions are regular.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 402

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

19. A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurses best response is:

a.

Dont worry about it. Youll do fine.

b.

Its normal to be anxious about labor. Lets discuss what makes you afraid.

c.

Labor is scary to think about, but the actual experience isnt.

d.

You can have an epidural. You wont feel anything.

ANS: B

Its normal to be anxious about labor. Lets discuss what makes you afraid allows the woman to share her concerns with the nurse and is a therapeutic communication tool. Dont worry about it. Youll do fine negates the womans fears and is not therapeutic. Labor is scary to think about, but the actual experience isnt negates the womans fears and offers a false sense of security. It is not true that every woman may have an epidural. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

PTS: 1 DIF: Cognitive Level: Application REF: 407

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

20. For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of:

a.

The onset of progressive, regular contractions.

b.

The bloody, or pink, show.

c.

The spontaneous rupture of membranes.

d.

Formulation of the womans plan of care for labor.

ANS: D

Labor care begins when progressive, regular contractions begin; the blood-tinged mucoid vaginal discharge appears; or fluid is discharged from the vagina. The woman and nurse can formulate their plan of care before labor or during treatment.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 405

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

21. Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?

a.

Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours

b.

Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours

c.

Lull: No contractions; dilation stable; duration of 20 to 60 minutes

d.

Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours

ANS: B

The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate, irregular contractions; dilation up to 3 cm; brownish-topale pink mucus, and a duration of 6 to 8 hours. No official lull phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 401

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

22. It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care?

a.

The patient is not considered to be in true labor (according to the Emergency Medical Treatment and Active Labor Act [EMTALA]) until a qualified health care provider says she is.

b.

The woman can have only her male partner or predesignated doula with her at assessment.

c.

The patients weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth.

d.

The nurse may exchange information about the patient with family members.

ANS: C

According to EMTALA, a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise. A woman can have anyone she wishes present for her support. The risk for CPD is especially great for petite women or those who have gained 16 kg or more. All patients should have their weight and BMI calculated on admission. This is part of standard nursing care on a maternity unit and not a regulatory concern. According to the Health Insurance Portability and Accountability Act (HIPAA), the patient must give consent for others to receive any information related to her condition.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 403

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

23. Leopold maneuvers would be an inappropriate method of assessment to determine:

a.

Gender of the fetus.

b.

Number of fetuses.

c.

Fetal lie and attitude.

d.

Degree of the presenting parts descent into the pelvis.

ANS: A

Leopold maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus is not a goal of the examination at this time.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 409

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

24. In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except:

a.

Frequency (how often contractions occur).

b.

Intensity (the strength of the contraction at its peak).

c.

Resting tone (the tension in the uterine muscle).

d.

Appearance (shape and height).

ANS: D

Uterine contractions are described in terms of frequency, intensity, duration, and resting tone.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 411

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

25. Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is:

a.

Usually directly over the fetal abdomen.

b.

In a vertex position heard above the mothers umbilicus.

c.

Heard lower and closer to the midline of the mothers abdomen as the fetus descends and rotates internally.

d.

In a breech position heard below the mothers umbilicus.

ANS: C

Nurses should be prepared for the shift. The PMI of the FHT usually is directly over the fetal back. In a vertex position it is heard below the mothers umbilicus. In a breech position it is heard above the mothers umbilicus.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 409

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

26. Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?

a.

An admission to the hospital at the start of labor

b.

When accelerations of the fetal heart rate (FHR) are noted

c.

On maternal perception of perineal pressure or the urge to bear down

d.

When membranes rupture

ANS: B

An accelerated FHR is a positive sign; however, variable decelerations merit a vaginal examination. Vaginal examinations should be performed when the woman is admitted, when she perceives perineal pressure or the urge to bear down, when her membranes rupture, when a significant change in her uterine activity has occurred, or when variable decelerations of the FHR are noted.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 411

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

27. With regard to a womans intake and output during labor, nurses should be aware that:

a.

The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia.

b.

Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated.

c.

Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery.

d.

When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly.

ANS: A

Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. Routine use of an enema is at best ineffective and may be harmful. A multiparous woman may feel the urge to defecate and it may mean birth will follow quickly, but not for a first-timer.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 417

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

28. If a woman complains of back labor pain, the nurse could best suggest that she:

a.

Lie on her back for a while with her knees bent.

b.

Do less walking around.

c.

Take some deep, cleansing breaths.

d.

Lean over a birth ball with her knees on the floor.

ANS: D

The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged.

PTS: 1 DIF: Cognitive Level: Application REF: 421

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

29. Which description of the phases of the second stage of labor is accurate?

a.

Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes

b.

Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes

c.

Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied

d.

Transitional phase: Woman laboring down, fetal station 0, duration 15 minutes

ANS: C

The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or laboring down, period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 425

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

30. Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when:

a.

The woman has a sudden episode of vomiting.

b.

The nurse is unable to feel the cervix during a vaginal examination.

c.

Bloody show increases.

d.

The woman involuntarily bears down.

ANS: B

The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced. Vomiting, an increase in bloody show, and involuntary bearing down are only suggestions of second-stage labor.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 425

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

31. A means of controlling the birth of the fetal head with a vertex presentation is:

a.

The Ritgen maneuver.

c.

The lithotomy position.

b.

Fundal pressure.

d.

The De Lee apparatus.

ANS: A

The Ritgen maneuver extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth. The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider. The De Lee apparatus is used to suction fluid from the infants mouth.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 434

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

32. Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)?

a.

A dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife

b.

A reddish-haired mother of two who is going through a breech birth

c.

A dark-skinned, first-time mother who is going through a long labor

d.

A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician

ANS: D

Reddish-haired women have tissue that is less distensible than that of darker-skinned women and therefore may have less efficient healing. First time mothers are also more at risk, especially with breech births, long second-stage labors, or rapid labors in which there is insufficient time for the perineum to stretch. The rate of episiotomies is higher when obstetricians rather than midwives attend births.

PTS: 1 DIF: Cognitive Level: Application REF: 435

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

33. Concerning the third stage of labor, nurses should be aware that:

a.

The placenta eventually detaches itself from a flaccid uterus.

b.

An expectant or active approach to managing this stage of labor reduces the risk of complications.

c.

It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.

d.

The major risk for women during the third stage is a rapid heart rate.

ANS: B

Active management facilitates placental separation and expulsion, thus reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 436

OBJ: Nursing Process: Planning, Implementation

MSC: Client Needs: Physiologic Integrity

34. For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?

a.

Telling the client to relax and that it wont hurt much

b.

Limiting the number of procedures that invade her body

c.

Reassuring the client that as the nurse you know what is best

d.

Allowing unlimited care providers to be with the client

ANS: B

The number of invasive procedures such as vaginal examinations, internal monitoring, and intravenous therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the clients recalling the phrases of her abuser (e.g., Relax, this wont hurt or Just open your legs.) The womans sense of control should be maintained at all times. The nurse should explain procedures at the clients pace and wait for permission to proceed. Protecting the clients environment by providing privacy and limiting the number of staff who observe the client will help to make her feel safe.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 406

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

35. As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance?

a.

Mexico

c.

Iran

b.

China

d.

India

ANS: A

A woman from Mexico may be stoic about discomfort until the second stage, at which time she will request pain relief. Fathers and female relatives are usually in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well. Fathers are usually not present in China. The Iranian father will not be present. Female support persons and female care providers are preferred. For many, a male caregiver is unacceptable. The father is usually not present in India, but female relatives are usually present. Natural childbirth methods are preferred.

PTS: 1 DIF: Cognitive Level: Application REF: 408

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

36. A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?

a.

Latent phase

c.

Second stage

b.

Active phase

d.

Third stage

ANS: B

The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta. This patient is in the active phase of labor.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 401

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

37. The primary difference between the labor of a nullipara and that of a multipara is the:

a.

Amount of cervical dilation.

c.

Level of pain experienced.

b.

Total duration of labor.

d.

Sequence of labor mechanisms.

ANS: B

Multiparas usually labor more quickly than nulliparas, thus making the total duration of their labor shorter. Cervical dilation is the same for all labors. The level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms remains the same with all labors.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 406

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

38. What is an essential part of nursing care for the laboring woman?

a.

Helping the woman manage the pain

b.

Eliminating the pain associated with labor

c.

Sharing personal experiences regarding labor and delivery to decrease her anxiety

d.

Feeling comfortable with the predictable nature of intrapartum care

ANS: A

Helping a woman manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Decreasing anxiety is important; however, managing pain is a top priority. The labor nurse should consistently deliver care based on the standard of care related to the maternity patient. Because of the unpredictable nature of labor, the nurse should always be alert for unanticipated events.

PTS: 1 DIF: Cognitive Level: Application REF: 414

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

39. A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are:

a.

Contraction pattern, amount of discomfort, and pregnancy history.

b.

Fetal heart rate, maternal vital signs, and the womans nearness to birth.

c.

Identification of ruptured membranes, the womans gravida and para, and her support person.

d.

Last food intake, when labor began, and cultural practices the couple desires.

ANS: B

All options describe relevant intrapartum nursing assessments; however, this focused assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. This includes: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices.

PTS: 1 DIF: Cognitive Level: Application REF: 430

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

40. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be:

a.

Admitted and prepared for a cesarean birth.

b.

Admitted for extended observation.

c.

Discharged home with a sedative.

d.

Discharged home to await the onset of true labor.

ANS: D

This situation describes a woman with normal assessments who is probably in false labor and will likely not deliver rapidly once true labor begins. There is no indication that further assessments or observations are indicated; therefore, the patient will be discharged along with instructions to return when contractions increase in intensity and frequency. Neither a cesarean birth nor a sedative is required at this time.

PTS: 1 DIF: Cognitive Level: Analysis REF: 403

OBJ: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

41. A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to:

a.

Ask her to turn to one side.

b.

Elevate her feet and legs.

c.

Take her blood pressure.

d.

Determine whether fetal tachycardia is present.

ANS: A

The womans supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental blood flow. Elevating her legs will not relieve the pressure from the inferior vena cava. If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side. Blood pressure readings may be obtained when the patient is in the appropriate and safest position.

PTS: 1 DIF: Cognitive Level: Application REF: 430

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

42. Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

a.

The fetal head is felt at 0 station during vaginal examination.

b.

Bloody mucus discharge increases.

c.

The vulva bulges and encircles the fetal head.

d.

The membranes rupture during a contraction.

ANS: C

A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 431

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

43. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant?

a.

7

c.

9

b.

8

d.

10

ANS: C

The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue hands and feet. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1.

PTS: 1 DIF: Cognitive Level: Application REF: 434

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

44. The nurse thoroughly dries the infant immediately after birth primarily to:

a.

Stimulate crying and lung expansion.

b.

Remove maternal blood from the skin surface.

c.

Reduce heat loss from evaporation.

d.

Increase blood supply to the hands and feet.

ANS: C

Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Rubbing the infant does stimulate crying; however, it is not the main reason for drying the infant. This process does not remove all the maternal blood.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 439

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

45. Women who have participated in childbirth education classes often bring a birth bag or Lamaze bag with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including (Select all that apply):

a.

Rolling pin.

d.

Stuffed animal or photo.

b.

Tennis balls.

e.

Candles.

c.

Pillow.

ANS: A, B, C, D

The rolling pin and tennis balls are used to provide counterpressure, especially if the woman is experiencing back labor. Although the facility has plenty of pillows, when the client brings her own, it is a reminder of home and provides added comfort. A stuffed animal or framed photo can be used to provide a focal point during contractions. Although many women find the presence of candles conducive to creating calm and relaxing surroundings, these are not suitable for a hospital birthing room environment. Oxygen may be in use, resulting in a fire hazard. Flameless candles are often sold in hospital gift shops. It is also important for the nurse to orient the patient and her family to the call bell and light switches to familiarize herself with the environment.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 403

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

MATCHING

The vaginal examination is an essential component of labor assessment. It reveals whether the patient is in true labor and enables the examiner to determine whether membranes have ruptured. This examination is often stressful and uncomfortable for the patient and should be performed only when indicated. Please match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

a.

After obtaining permission, gently insert the index and middle fingers into the vagina.

b.

Explain findings to the patient.

c.

Position the woman to prevent supine hypotension.

d.

Use sterile gloves and soluble gel for lubrication.

e.

Document findings and report to the provider.

f.

Cleanse the perineum and vulva if necessary.

g.

Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

46. Step 1

47. Step 2

48. Step 3

49. Step 4

50. Step 5

51. Step 6

52. Step 7

46. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

47. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

48. ANS: F PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

49. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

50. ANS: G PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

51. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

52. ANS: E PTS: 1 DIF: Cognitive Level: Application

REF: 414 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: The vaginal examination should be performed on admission, before administering analgesics, when a significant change in uterine activity has occurred, on maternal perception of perineal pressure, when membranes rupture, or when you note variable decelerations of the fetal heart rate. A full explanation of the examination and support of the woman are important in reducing the level of stress and discomfort.

The labor process is an exciting and anxious time for the patient and her partner and family. In a relatively short period of time, they experience one of the most profound changes in their lives. Nursing care management focuses on assessment and support throughout labor and birth, with the goal of ensuring the best possible outcome for mother and newborn. Please match each nursing diagnosis with the appropriate intervention needed to achieve the expected outcome.

a.

Anxiety related to labor and the birthing process

b.

Acute pain related to contractions

c.

Risk for impaired urinary elimination

d.

Risk for impaired individual coping

e.

Fatigue related to energy expenditure during labor and birth

53. Instruct the patient and partner in the use of specific relaxation techniques.

54. Continue to provide comfort measures and minimize distractions.

55. Group care activities as much as possible.

56. Orient the patient and family to the labor and birth unit.

57. Encourage frequent voiding and catheterize if necessary.

53. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 416 OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

NOT: To reduce anxiety, the nurse can also assess the womans knowledge and experience, discuss the expected progression of labor, and actively involve the woman in her care. Acute pain related to contractions may be addressed by nonpharmacologic and pharmacologic methods of pain relief including relaxation techniques. Impaired urinary elimination occurs as a result of sensory impairment secondary to labor. The bladder should be palpated on a frequent basis, and the nurse must remember that the patient will likely require assistance to void. The risk for ineffective individual coping may be ameliorated by minimizing distractions, as well as providing the patient and her partner with ongoing feedback and encouragement. Fatigue is to be expected; the patient should be monitored as to her level of fatigue, and the family should be educated about the need for rest.

54. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 417 OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

NOT: To reduce anxiety, the nurse can also assess the womans knowledge and experience, discuss the expected progression of labor, and actively involve the woman in her care. Acute pain related to contractions may be addressed by nonpharmacologic and pharmacologic methods of pain relief including relaxation techniques. Impaired urinary elimination occurs as a result of sensory impairment secondary to labor. The bladder should be palpated on a frequent basis, and the nurse must remember that the patient will likely require assistance to void. The risk for ineffective individual coping may be ameliorated by minimizing distractions, as well as providing the patient and her partner with ongoing feedback and encouragement. Fatigue is to be expected; the patient should be monitored as to her level of fatigue, and the family should be educated about the need for rest.

55. ANS: E PTS: 1 DIF: Cognitive Level: Application

REF: 417 OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

NOT: To reduce anxiety, the nurse can also assess the womans knowledge and experience, discuss the expected progression of labor, and actively involve the woman in her care. Acute pain related to contractions may be addressed by nonpharmacologic and pharmacologic methods of pain relief including relaxation techniques. Impaired urinary elimination occurs as a result of sensory impairment secondary to labor. The bladder should be palpated on a frequent basis, and the nurse must remember that the patient will likely require assistance to void. The risk for ineffective individual coping may be ameliorated by minimizing distractions, as well as providing the patient and her partner with ongoing feedback and encouragement. Fatigue is to be expected; the patient should be monitored as to her level of fatigue, and the family should be educated about the need for rest.

56. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 416 OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

NOT: To reduce anxiety, the nurse can also assess the womans knowledge and experience, discuss the expected progression of labor, and actively involve the woman in her care. Acute pain related to contractions may be addressed by nonpharmacologic and pharmacologic methods of pain relief including relaxation techniques. Impaired urinary elimination occurs as a result of sensory impairment secondary to labor. The bladder should be palpated on a frequent basis, and the nurse must remember that the patient will likely require assistance to void. The risk for ineffective individual coping may be ameliorated by minimizing distractions, as well as providing the patient and her partner with ongoing feedback and encouragement. Fatigue is to be expected; the patient should be monitored as to her level of fatigue, and the family should be educated about the need for rest.

57. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 417 OBJ: Nursing Process: Diagnosis, Planning

MSC: Client Needs: Physiologic Integrity

NOT: To reduce anxiety, the nurse can also assess the womans knowledge and experience, discuss the expected progression of labor, and actively involve the woman in her care. Acute pain related to contractions may be addressed by nonpharmacologic and pharmacologic methods of pain relief including relaxation techniques. Impaired urinary elimination occurs as a result of sensory impairment secondary to labor. The bladder should be palpated on a frequent basis, and the nurse must remember that the patient will likely require assistance to void. The risk for ineffective individual coping may be ameliorated by minimizing distractions, as well as providing the patient and her partner with ongoing feedback and encouragement. Fatigue is to be expected; the patient should be monitored as to her level of fatigue, and the family should be educated about the need for rest.

Leave a Reply