Chapter 12: Nursing Care of the Family during Labor and Birth My Nursing Test Banks

Lowdermilk: Maternity Nursing, 8th Edition

Chapter 12: Nursing Care of the Family during Labor and Birth

Test Bank 

MULTIPLE CHOICE

1. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates that the woman understands the instructions when she states:

a. True labor contractions will subside when I walk around.
b. True labor contractions will cause discomfort over the top of my uterus.
c. True labor contractions will continue and get stronger even if I relax and take a shower.
d. True labor contractions will remain irregular but become stronger.

ANS: C

Feedback
A 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.
B 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.
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.
D 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.

DIF:Cognitive Level: ApplicationREF:338

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

2. 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

Feedback
A The initial nursing activity should be to gather data about the womans status. The amniotic membranes may or may not spontaneously rupture during labor. The woman may be instructed to stay home until the uterine contractions become strong and regular.
B The initial nursing activity should be to gather data about the womans status. After this assessment has been made, 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 woman or her primary health care provider.
C Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.
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 her assessment and gather data.

DIF:Cognitive Level: ApplicationREF:337

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

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

a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension

ANS: A

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

DIF:Cognitive Level: ComprehensionREF:352

OBJ:Client Needs: Physiologic Integrity

TOP:Nursing Process: Planning, Diagnosis

4. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:

a. Notify the womans primary health care provider immediately.
b. Prepare to administer an oxytocic to stimulate uterine activity.
c. Document the findings because they reflect the expected contraction pattern for the active phase of labor.
d. Prepare the woman for the onset of the second stage of labor.

ANS: C

Feedback
A Nothing indicates a need to notify the primary care provider at this time.
B Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor.
C The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the patients medical record. This labor pattern indicates that the woman is in the active phase of the first stage of labor.
D This labor pattern indicates that the woman is in active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

DIF:Cognitive Level: ApplicationREF:352

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

5. 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.
b. Descent of the fetus.
c. Rupture of the amniotic membranes.
d. Increase in bloody show.

ANS: A

Feedback
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.
B Descent of the fetus, or engagement, may occur before labor.
C Rupture of membranes may occur with or without the presence of labor.
D Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.

DIF:Cognitive Level: ComprehensionREF:349

OBJ:Client Needs: Health Promotion and Maintenance

TOP:Nursing Process: Assessment, Diagnosis

6. 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

Feedback
A A vaginal examination should be performed only when indicated by the status of the woman and her fetus.
B The woman should be positioned to avoid supine hypotension.
C The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.
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.

DIF:Cognitive Level: ApplicationREF:351

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

7. 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

Feedback
A Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent.
B The nurse may notify the primary care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurses priority is to assess fetal well-being.
C 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.
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.

DIF:Cognitive Level: ApplicationREF:352

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

8. 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. A period of rest and relative calm.
d. Show an increase in bright red bloody show.

ANS: C

Feedback
A 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.
B Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage.
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. The woman is quiet and often relaxes with her eyes closed between contractions.
D An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

DIF:Cognitive Level: ComprehensionREF:360

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

9. 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

Feedback
A Upright positions and squatting both may enhance the progress of fetal descent.
B 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.
C The epidural may mask the sensations and muscle control needed for the woman to push effectively.
D 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, resulting in fetal hypoxia.

DIF:Cognitive Level: ComprehensionREF:362

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

10. Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3 to 4 minutes. The nurse would report this as:

a. First stage, latent phase.
b. First stage, active phase.
c. First stage, transition phase.
d. Second stage, latent phase.

ANS: B

Feedback
A 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.
B This maternal progress indicates that the woman is in the active phase of the first stage of labor.
C 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.
D During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of laboring down.

DIF:Cognitive Level: ComprehensionREF:337

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

11. 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

Feedback
A The care given immediately after the birth focuses on assessing and stabilizing the newborn.
B 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.
C The care given immediately after birth focuses on assessing and stabilizing the newborn. 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.
D 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.

DIF:Cognitive Level: ComprehensionREF:372

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

12. 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

Feedback
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.
B Cervical tears that do not extend to the vagina result in minimal blood loss.
C 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.
D If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

DIF:Cognitive Level: ComprehensionREF:376

OBJ:Client Needs: Health Promotion and Maintenance

TOP:Nursing Process: Assessment, Diagnosis

13. The nurse expects to administer an oxytocic (uterotonic such as Pitocin, Methergine) to a woman after expulsion of her placenta to:

a. Relieve pain.
b. Stimulate uterine contraction.
c. Prevent infection.
d. Facilitate rest and relaxation.

ANS: B

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

DIF:Cognitive Level: KnowledgeREF:376

OBJ:Client Needs: Health Promotion and Maintenance

TOP:Nursing Process: Planning, Implementation

14. 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

Feedback
A Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth.
B Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.
C 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.
D Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth. Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.

DIF:Cognitive Level: ComprehensionREF:365

OBJ:Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

15. 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

Feedback
A This statement negates the womans fears and is not therapeutic.
B This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool.
C This statement negates the womans fears and offers a false sense of security.
D This statement is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

DIF:Cognitive Level: ApplicationREF:343

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

16. Vaginal examinations should be performed by the nurse under all of these circumstances except:

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

Feedback
A 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.
B An accelerated FHR is a positive sign; however, variable decelerations merit a vaginal examination.
C 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.
D 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.

DIF:Cognitive Level: KnowledgeREF:350

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

17. 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

Feedback
A Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration.
B Routine IV fluids during labor are unlikely to be beneficial and may be harmful.
C Routine use of an enema is at best ineffective and may be harmful.
D This is true for a multiparous woman but not for a first-timer.

DIF:Cognitive Level: ComprehensionREF:352

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

18. If a woman complains of back labor pain, the nurse might 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

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

DIF:Cognitive Level: ApplicationREF:356

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

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

a. Latent phase: Feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes
b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes
c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varies
d. Transitional phase: Woman laboring down, fetal station is 0, duration is 15 minutes

ANS: C

Feedback
A 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.
B The second stage of labor has no active phase.
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.
D The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

DIF:Cognitive Level: ComprehensionREF:360, 362

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

20. 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 tries to bear down.

ANS: B

Feedback
A This is a suggestion of second-stage labor. 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.
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.
C This is a suggestion of second-stage labor. 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.
D This is a suggestion of second-stage labor. 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.

DIF:Cognitive Level: KnowledgeREF:360

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

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

a. The Ritgen maneuver.
b. Fundal pressure.
c. The lithotomy position.
d. The De Lee apparatus.

ANS: A

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

DIF:Cognitive Level: KnowledgeREF:372

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

22. 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 woman 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 woman view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?

a. Telling the woman to relax and that it wont hurt much
b. Limiting the number of procedures that invade her body
c. Reassuring the woman that as the nurse you know what is best
d. Allowing unlimited care providers to be with the woman

ANS: B

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

DIF:Cognitive Level: ComprehensionREF:342

OBJ:Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

23. 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
b. China
c. Iran
d. India

ANS: A

Feedback
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.
B Fathers are usually not present.
C The father will not be present. Female support persons and female care providers are preferred. For many a male caregiver is unacceptable.
D The father is usually not present, but female relatives are usually present. Natural childbirth methods are preferred.

DIF:Cognitive Level: ApplicationREF:344

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

MULTIPLE RESPONSE

1. Women who have participated in childbirth education classes often bring a birth plan with them to the hospital. This document includes the couples preference related to (choose all that apply):

a. Presence of companions.
b. Clothing to be worn.
c. Care and handling of the newborn.
d. Medical interventions.
e. Environmental modifications.

ANS: A, B, C, D, E

Feedback
Correct All of these might be included in the couples birth plan. Other items might include the presence of non-essential medical personnel (students), labor activities such as the tub or ambulation, preferred comfort and relaxation methods, and any cultural or religious requirements.
Incorrect None of the above. The following website has some examples of birth plans and provides couples with an interactive birth plan to assist them in preparation for their birth (www.childbirth.org).

DIF:Cognitive Level: ApplicationREF:341

OBJ: Client Needs: Physiologic and Psychologic Integrity TOP: Nursing Process: Planning

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