Chapter 13: Nursing Care During Labor and Birth My Nursing Test Banks

Chapter 13: Nursing Care During Labor and Birth

MULTIPLE CHOICE

1. The nurse is preparing to perform Leopolds maneuvers. Why are Leopolds maneuvers used by practitioners?

a.

To determine the status of the membranes

b.

To determine cervical dilation and effacement

c.

To determine the best location to assess the fetal heart rate

d.

To determine whether the fetus is in the posterior position

ANS: C

Leopolds maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

PTS: 1 DIF: Cognitive Level: Application REF: 227

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

2. Which comfort measure should a nurse use to assist a laboring woman to relax?

a.

Recommend frequent position changes.

b.

Palpate her filling bladder every 15 minutes.

c.

Offer warm wet cloths to use on the clients face and neck.

d.

Keep the room lights lit so the client and her coach can see everything.

ANS: A

Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

PTS: 1 DIF: Cognitive Level: Application REF: 236

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

3. Which assessment finding could indicate hemorrhage in the postpartum patient?

a.

Elevated pulse rate

b.

Elevated blood pressure

c.

Firm fundus at the midline

d.

Saturation of two perineal pads in 4 hours

ANS: A

An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

PTS: 1 DIF: Cognitive Level: Analysis REF: 224

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

4. Which is an essential part of nursing care for a laboring client?

a.

Helping the woman manage the pain

b.

Eliminating the pain associated with labor

c.

Feeling comfortable with the predictable nature of intrapartal care

d.

Sharing personal experiences regarding labor and birth to decrease her anxiety

ANS: A

Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 220

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

5. A client at 40 weeks gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:

a.

fetal movement.

b.

irregular contractions for 1 hour.

c.

a trickle of fluid from the vagina.

d.

thick pink or dark red vaginal mucus.

ANS: C

A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Application REF: 221

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

6. Which client at term should go to the hospital or birth center the soonest after labor begins?

a.

Gravida 2, para 1, who lives 10 minutes away

b.

Gravida 1, para 0, who lives 40 minutes away

c.

Gravida 2, para 1, whose first labor lasted 16 hours

d.

Gravida 3, para 2, whose longest previous labor was 4 hours

ANS: D

Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

PTS: 1 DIF: Cognitive Level: Analysis REF: 221

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Safe and Effective Care Environment

7. 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.

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

d.

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

ANS: B

All options describe relevant intrapartum nursing assessments, but the focus 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. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the womans gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

PTS: 1 DIF: Cognitive Level: Application REF: 222

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. 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 client to be:

a.

discharged home with a sedative.

b.

admitted for extended observation.

c.

admitted and prepared for a cesarean birth.

d.

discharged home to await the onset of true labor.

ANS: D

The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 233

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

9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?

a.

Inform the mother that the rate is normal.

b.

Reassess the fetal heart rate in 5 minutes because the rate is too high.

c.

Report the fetal heart rate to the physician or nurse-midwife immediately.

d.

Tell the mother that she is going to have a boy because the heart rate is fast.

ANS: A

The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 235

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

10. Which should the nurse recognize as being associated with fetal compromise?

a.

Active fetal movements

b.

Fetal heart rate in the 140s

c.

Contractions lasting 90 seconds

d.

Meconium-stained amniotic fluid

ANS: D

When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

PTS: 1 DIF: Cognitive Level: Application REF: 235

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

a.

Every 15 minutes

b.

Every 30 minutes

c.

Every 45 minutes

d.

Every 1 hour

ANS: B

For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

PTS: 1 DIF: Cognitive Level: Application REF: 231

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

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

a.

Bloody mucous discharge increases.

b.

The vulva bulges and encircles the fetal head.

c.

The membranes rupture during a contraction.

d.

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

ANS: B

A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. 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. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

PTS: 1 DIF: Cognitive Level: Analysis REF: 233

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

13. During labor a vaginal examination should be performed only when necessary because of the risk of:

a.

infection.

b.

fetal injury.

c.

discomfort.

d.

perineal trauma.

ANS: A

Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

PTS: 1 DIF: Cognitive Level: Understanding REF: 231, 233

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

14. A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husbands hand away and shouts, Dont touch me! This behavior is most likely:

a.

abnormal labor.

b.

a sign that she needs analgesia.

c.

normal and related to hyperventilation.

d.

common during the transition phase of labor.

ANS: D

The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

PTS: 1 DIF: Cognitive Level: Application REF: 223

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

15. 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. The Apgar score for this infant is:

a.

7.

b.

8.

c.

9.

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. 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. The infant had 1 point deducted because of the blue color of the hands and feet.

PTS: 1 DIF: Cognitive Level: Application REF: 249

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

16. If a womans fundus is soft 30 minutes after birth, the nurses first response should be to:

a.

massage the fundus.

b.

take the blood pressure.

c.

notify the physician or nurse-midwife.

d.

place the woman in Trendelenburg position.

ANS: A

The nurses first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

PTS: 1 DIF: Cognitive Level: Application REF: 249

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

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

a.

reduce heat loss from evaporation.

b.

stimulate crying and lung expansion.

c.

increase blood supply to the hands and feet.

d.

remove maternal blood from the skin surface.

ANS: A

Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

PTS: 1 DIF: Cognitive Level: Understanding REF: 248

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

18. The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

a.

Request a social service consult for psychosocial support.

b.

Observe for other signs that the mother may not be accepting of the infant.

c.

Document this evidence of normal early maternal-infant attachment behavior.

d.

Determine whether the mother is too fatigued to interact normally with her infant.

ANS: C

Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

PTS: 1 DIF: Cognitive Level: Analysis REF: 251

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

19. Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?

a.

Fluid volume deficit (FVD) related to fluid loss during labor and birth process

b.

Fatigue related to length of labor requiring increased energy expenditure

c.

Acute pain related to increased intensity of contractions

d.

Anxiety related to imminent birth process

ANS: D

A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 244

OBJ: Nursing Process Step: Nursing Diagnosis

MSC: Client Needs: Psychosocial Integrity

20. Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?

a.

Length of second-stage labor is 2 hours.

b.

Client has received an epidural for pain control during the labor process.

c.

Client is using breathing techniques during contractions to maximize pain relief.

d.

Client is receiving parenteral fluids during the course of labor to maintain hydration.

ANS: B

A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

PTS: 1 DIF: Cognitive Level: Application REF: 244

OBJ: Nursing Process Step: Diagnosis

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

21. A gravida 1, para 0, 38 weeks gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, 1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?

a.

Performing more frequent vaginal exams will not make the labor go any quicker.

b.

Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.

c.

Tell the client that she will check every 30 minutes.

d.

Medicate the client as needed for anxiety so that the labor can progress.

ANS: B

Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address clients anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 231, 233

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

22. When using the second Leopolds maneuver in fetal assessment, the nurse would palpate (the):

a.

both sides of the maternal abdomen.

b.

lower abdomen above the symphysis pubis.

c.

both upper quadrants of the maternal abdomen .

d.

lower abdomen for flexion of the presenting part.

ANS: A

The second Leopolds maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

PTS: 1 DIF: Cognitive Level: Application REF: 230, 231

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

23. A nursing priority during admission of a laboring client who has not had prenatal care is:

a.

obtaining admission labs.

b.

identifying labor risk factors.

c.

discussing her birth plan choices.

d.

explaining importance of prenatal care.

ANS: B

When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patients history has been completed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 223

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

24. The nurse has given the newborn an Apgar score of 5. She should then:

a.

begin ventilation and compressions.

b.

do nothing except place the infant under a radiant warmer.

c.

observe the infant and recheck the score after 10 minutes.

d.

gently stimulate by rubbing the infants back while administering O2.

ANS: D

An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborns transition to extrauterine life.

PTS: 1 DIF: Cognitive Level: Application REF: 249

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

25. The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the clients record?

a.

Fetal heart rate

b.

Pain level

c.

Test results ensuring that the fluid is not urine

d.

The clients understanding of the event

ANS: A

Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The clients understanding of the event would only need to be documented if it presents a problem.

PTS: 1 DIF: Cognitive Level: Understanding REF: 222

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

26. At 5 minutes after birth, the nurse assesses that the neonates heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign?

a.

7

b.

8

c.

9

d.

10

ANS: B

The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

PTS: 1 DIF: Cognitive Level: Analysis REF: 248

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

27. The gynecologist performs an amniotomy. What will the nurses role include immediately following the procedure?

a.

Assessing for ballottement

b.

Conducting a pH and/or fern test

c.

Labeling of specimens for chromosomal analysis

d.

Recording the character and amount of amniotic fluid

ANS: D

An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

PTS: 1 DIF: Cognitive Level: Understanding REF: 229

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

28. The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

a.

Bloody

b.

Clear with bits of vernix caseosa

c.

Green and thick

d.

Yellow and cloudy with foul odor

ANS: B

Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

PTS: 1 DIF: Cognitive Level: Application REF: 229

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

29. The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?

a.

To apply internal monitoring electrodes

b.

To assess for Goodells sign

c.

To determine cervical dilation and effacement

d.

To determine strength of contractions

ANS: C

The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodells sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 229

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

30. A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?

a.

Obtain a fetal heart rate.

b.

Determine the estimated due date.

c.

Auscultate anterior and posterior breath sounds.

d.

Ask the client when she last had something to eat.

ANS: C

On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and painlocation, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 227

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

31. The health care provider has asked the nurse to prepare for an amniotomy. What is the nurses priority action with this procedure?

a.

Perform Leopolds maneuvers.

b.

Determine the color of the amniotic fluid.

c.

Assess the fetal heart rate immediately after the procedure.

d.

Prepare the patient for a change in her pain level after the procedure.

ANS: C

An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopolds maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 229

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

32. The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?

a.

18-gauge

b.

20-gauge

c.

22-gauge

d.

24-gauge

ANS: A

The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

PTS: 1 DIF: Cognitive Level: Understanding REF: 229

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

33. The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?

a.

Place the catheter as quickly as possible.

b.

Place a small pillow under the patients left hip.

c.

Omit the use of a cleansing agent, such as Betadine.

d.

Set up the catheter tray before positioning the patient.

ANS: B

To promote placental function, the nurse can place a small pillow or rolled blanket under the patients left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

PTS: 1 DIF: Cognitive Level: Analysis REF: 235

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

34. The nurse examines a primiparas cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurses priority action?

a.

Palpate her bladder for fullness.

b.

Assess the frequency and duration of her contractions.

c.

Determine who will stay with the patient for the birth.

d.

Encourage the patient to exhale in short breaths with contractions.

ANS: D

Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patients urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

PTS: 1 DIF: Cognitive Level: Analysis REF: 237

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

35. The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the babys head?

a.

Expulsion

b.

Restitution

c.

Internal rotation

d.

External rotation

ANS: B

After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head.

PTS: 1 DIF: Cognitive Level: Understanding REF: 247

OBJ: Nursing Process Step: Planning MSC: Client needs: Health Promotion and Maintenance

36. The nurse is performing Leopolds maneuvers on a client. Which figure depicts the Leopolds maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis. Refer to Figures a to d.

a.

b.

c.

d.

ANS: C

The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is done by palpating the suprapubic area. Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, the grasping movement of the fingers moves it upward in the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus. Palpating the uterine fundus distinguishes between a cephalic and breech presentation. Holding the left hand steady on one side of the uterus while palpating the opposite side of the uterus determines on which side of the uterus is the fetal back and on which side are the fetal arms and legs. Placing your hands on each side of the uterus with fingers pointed toward the inlet determines whether the head is flexed (vertex) or extended (face).

PTS: 1 DIF: Cognitive Level: Analysis REF: 230

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

37. A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)

a.

Less maternal fatigue

b.

Less birth canal injuries

c.

Decreased pushing time

d.

Faster descent of the fetus

e.

An increase in frequency of contractions

ANS: A, B, C

Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her bodys signals. A brief slowing of contractions often occurs at the beginning of the second stage.

PTS: 1 DIF: Cognitive Level: Analysis REF: 238

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

38. Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.)

a.

Place the infant covered with blankets in the radiant warmer.

b.

Dry the infant off with sterile towels.

c.

Place stockinette cap on infants head.

d.

Bathe the newborn within 30 minutes of birth.

e.

Remove wet linen as needed.

ANS: B, C, E

Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infants head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period.

PTS: 1 DIF: Cognitive Level: Analysis REF: 248

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

39. When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.)

a.

Check the DTR each shift.

b.

Monitor and record vital signs frequently during the course of labor.

c.

Document the FHR pattern, noting baseline and response to contraction patterns.

d.

Indicate on the EFM tracing when maternal position changes are done.

e.

Provide food, as tolerated, during the course of labor.

ANS: B, C, D

Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 229

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

40. Which interventions are required following an amniotomy procedure? (Select all that apply.)

a.

Notation related to amount of fluid expelled

b.

Color and consistency of fluid

c.

Fetal heart rate

d.

Maternal blood pressure

e.

Maternal heart rate

ANS: A, B, C

Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

PTS: 1 DIF: Cognitive Level: Application REF: 229

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

41. The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)

a.

Maternal hypotension

b.

Fetal heart rate of 140 to 150 bpm

c.

Meconium-stained amniotic fluid

d.

Maternal fever38 C (100.4 F) or higher

e.

Complete uterine relaxation of more than 30 seconds between contractions

ANS: A, C, D

Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38 C [100.4 F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

PTS: 1 DIF: Cognitive Level: Analysis REF: 234

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

42. The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

a.

Soft boggy uterus

b.

Maternal temperature of 99 F

c.

High uterine fundus displaced to the right

d.

Intense vaginal pain unrelieved by analgesics

e.

Half of a lochia pad saturated in the first hour after birth

ANS: A, C, D

Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

PTS: 1 DIF: Cognitive Level: Analysis REF: 249

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

SHORT ANSWER

43. The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places.

_____ mL

ANS:

0.75

Use the medication calculation formula to calculate the correct dose:

Desired/available volume = milliliters per dose

(0.3 mg/0.4 mg) 1 mL = 0.75 mL/dose

PTS: 1 DIF: Cognitive Level: Application REF: 249

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

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