Chapter 16: Giving Birth My Nursing Test Banks

Chapter 16: Giving Birth

Test Bank

MULTIPLE CHOICE

1. The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products

a.

Continues except when placental functions are reduced

b.

Increases as blood pressure decreases

c.

Diminishes as the spiral arteries are compressed

d.

Is not significantly affected

ANS: C

Feedback

A

The maternal blood supply to the placenta gradually stops with contractions.

B

The exchange of oxygen and waste products decreases.

C

During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle.

D

The exchange of oxygen and waste products is affected by contractions.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 320

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

2. Which statement is the best rationale for assessing maternal vital signs between contractions?

a.

During a contraction, assessing fetal heart rates is the priority.

b.

Maternal circulating blood volume increases temporarily during contractions.

c.

Maternal blood flow to the heart is reduced during contractions.

d.

Vital signs taken during contractions are not accurate.

ANS: B

Feedback

A

It is important to monitor fetal response to contractions, but the question is concerned with the maternal vital signs.

B

During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume, which in turn temporarily increases blood pressure and slows pulse.

C

Maternal blood flow is increased during a contraction.

D

Vital signs are altered by contractions but are considered accurate for that period of time.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 319

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

3. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?

a.

Engagement

b.

Extension

c.

Internal rotation

d.

External rotation

ANS: A

Feedback

A

Engagement occurs when the presenting part fully enters the pelvic inlet.

B

Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend.

C

Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis.

D

External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 329

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

4. To adequately care for patients, the nurse understands that labor contractions facilitate cervical dilation by

a.

Contracting the lower uterine segment

b.

Enlarging the internal size of the uterus

c.

Promoting blood flow to the cervix

d.

Pulling the cervix over the fetus and amniotic sac

ANS: D

Feedback

A

The contractions are stronger at the fundus.

B

The internal size becomes smaller with the contractions; this helps to push the fetus down.

C

Blood flow decreases to the uterus during a contraction.

D

Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 319

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

5. It is important for the nurse providing care during labor to be aware that pregnant women can usually tolerate the normal blood loss associated with childbirth because they have

a.

A higher hematocrit

b.

Increased blood volume

c.

A lower fibrinogen level

d.

Increased leukocytes

ANS: B

Feedback

A

The hematocrit decreases with pregnancy due to the high fluid volume.

B

Women have a significant increase in blood volume during pregnancy. After delivery, the additional circulating volume is no longer necessary.

C

Fibrinogen levels increase with pregnancy.

D

Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 320

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

6. To assess the duration of labor contractions, the nurse determines the time

a.

From the beginning of one contraction to the beginning of the next

b.

From the beginning to the end of each contraction

c.

Of the strongest intensity of each contraction

d.

Of uterine relaxation between two contractions

ANS: B

Feedback

A

This is the frequency of the contractions.

B

Duration of labor contractions is the average length of contractions from beginning to end.

C

This is the strength or intensity of the contractions.

D

This is the interval of the contraction phase.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 318

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

7. To adequately teach patients about the process of labor, the nurse knows that which event is the best indicator of true labor?

a.

Bloody show

b.

Cervical dilation and effacement

c.

Fetal descent into the pelvic inlet

d.

Uterine contractions every 7 minutes

ANS: B

Feedback

A

Bloody show can occur before true labor.

B

The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix.

C

Fetal descent can occur before true labor.

D

False labor may have contractions that occur this frequently, but it is usually inconsistent.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 329

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

8. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?

a.

Descent

b.

Engagement

c.

Flexion

d.

Station

ANS: C

Feedback

A

Descent is the moving of the fetus through the birth canal.

B

Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic inlet.

C

Flexion of the fetal head allows the smallest head diameters pass through the pelvis.

D

The station is the relationship of the fetal presenting part to the level of the ischial spines.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 329

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

9. What results from the adaptation of the fetus to the size and shape of the pelvis?

a.

Lightening

b.

Lie

c.

Molding

d.

Presentation

ANS: C

Feedback

A

Lightening is the descent of the fetus toward the pelvic inlet before labor.

B

Lie is the relationship of the long axis of the fetus to the long axis of the mother.

C

The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis.

D

Presentation is the fetal part that first enters the pelvic inlet.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 321

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

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

a.

Latent phase

b.

Active phase

c.

Second stage

d.

Third stage

ANS: B

Feedback

A

The latent phase is from the beginning of true labor until 3 cm of cervical dilation.

B

The active phase of labor is characterized by cervical dilation of 4 to 7 cm.

C

The second stage of labor begins when the cervix is completely dilated until the birth of the baby.

D

The third stage of labor is from the birth of the baby until the expulsion of the placenta.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 329

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

11. To teach and support the woman in labor, the nurse explains that the strongest part of a labor contraction is the

a.

Increment

b.

Acme

c.

Decrement

d.

Interval

ANS: B

Feedback

A

The increment is the beginning of the contractions until it reaches the peak.

B

The acme is the peak or period of greatest strength during the middle of a contraction cycle.

C

The decrement occurs after the peak until the contraction ends.

D

The interval is the period between the end of the contraction and the beginning of the next.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 318

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

12. What occurrence is associated with cervical dilation and effacement?

a.

Bloody show

b.

False labor

c.

Lightening

d.

Bladder distention

ANS: A

Feedback

A

As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries.

B

Cervical dilation and effacement do not occur with false labor.

C

Lightening is the descent of the fetus toward the pelvic inlet before labor.

D

Bladder distention occurs when the bladder is not empted frequently. It may slow down the decent of the fetus during labor.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 329

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

13. To be aware of potential risks to the laboring woman, the nurse understands that a breech presentation is associated with

a.

Umbilical cord compression

b.

More rapid labor

c.

A high risk of infection

d.

Maternal perineal trauma

ANS: A

Feedback

A

The umbilical cord can be compressed between the fetal body and the maternal pelvis when the body has been born but the head remains within the pelvis.

B

Breech presentation is not associated with a more rapid labor.

C

There is no higher risk of infection with a breech birth.

D

There is no higher risk for perineal trauma with a breech birth.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 325

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

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

a.

Amount of cervical dilation

b.

Total duration of labor

c.

Level of pain experienced

d.

Sequence of labor mechanisms

ANS: B

Feedback

A

Cervical dilation is the same for all labors.

B

Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter.

C

Level of pain is individual to the woman, not to the number of labors she has experienced.

D

The sequence of labor mechanisms is the same with all labors.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 335

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

15. Which maternal factor may inhibit fetal descent and require further nursing interventions?

a.

Decreased peristalsis

b.

A full bladder

c.

Reduction in internal uterine size

d.

Rupture of membranes

ANS: B

Feedback

A

Peristalsis does not influence fetal descent.

B

A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part.

C

Contractions will reduce the internal uterine size in order to assist fetal descent.

D

Rupture of membranes will assist in the fetal descent.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 320

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

16. Leopolds maneuvers are used by practitioners to determine

a.

The best location to assess the fetal heart rate (FHR)

b.

Cervical dilation and effacement

c.

Whether the fetus is in the posterior position

d.

The status of the membranes

ANS: A

Feedback

A

Leopolds maneuvers are often performed before assessing the FHR. These maneuvers help identify the best location to obtain the FHR.

B

Dilation and effacement are best determined by vaginal examination.

C

Assessment of fetal position is more accurate with vaginal examination.

D

A Nitrazine or ferning test can be performed to determine the status of the fetal membranes.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 342

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

17. Which comfort measure should the nurse use to assist the laboring woman to relax?

a.

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

b.

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

c.

Palpate her filling bladder every 15 minutes.

d.

Recommend frequent position changes.

ANS: D

Feedback

A

Soft, indirect lighting is more soothing than irritating bright lights.

B

Women in labor become hot and perspire. Cool cloths are much better

C

A full bladder intensifies labor pain. The bladder should be emptied every 2 hours.

D

Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 347

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

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

a.

Firm fundus at the midline

b.

Saturation of two perineal pads in 4 hours

c.

Elevated blood pressure

d.

Elevated pulse rate

ANS: D

Feedback

A

A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site.

B

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.

C

If the blood volume were diminishing, the blood pressure would decrease.

D

An increasing pulse rate is an early sign of excessive blood loss.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 360

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

19. 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 intrapartal care.

ANS: A

Feedback

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.

B

Labor pain cannot be fully relieved.

C

Decreasing anxiety is important, but managing pain is a top priority.

D

The labor nurse should always be assessing for unpredictable occurrences.

PTS: 1 DIF: Cognitive Level: Application REF: p. 317

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

20. A woman at 40 weeks of gestation should be instructed to go to a hospital or birth center for evaluation when she experiences

a.

A trickle of fluid from the vagina

b.

Thick pink or dark red vaginal mucus

c.

Irregular contractions for 1 hour

d.

Fetal movement

ANS: A

Feedback

A

A trickle of fluid from the vagina may indicate rupture of the membranes requiring evaluation for infection or cord compression.

B

Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

C

This is a sign of false labor and does not require further assessment.

D

The lack of fetal movement needs further assessment.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 335

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

21. Which patient 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 3 para 2 whose longest previous labor was 4 hours

d.

Gravida 2 para 1 whose first labor lasted 16 hours

ANS: C

Feedback

A

A gravida 2 is expected to have a longer labor than the gravida 3. The fact that she lives close to the hospital allows her to stay home for a longer period of time.

B

A gravida 1 is expected to have the longest labor.

C

Multiparous women usually have shorter labors than do nulliparous women. The woman described in option c is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances.

D

The gravida 2 is expected to have a longer labor than the gravida 3, especially since her first labor was 16 hours.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 335

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

22. 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

Feedback

A

This is an important nursing assessment, but does not take priority if the birth is imminent.

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.

C

This is an assessment that can occur later in the admission process if time permits.

D

This part of the assessment can occur later in the admission process if time permits.

PTS: 1 DIF: Cognitive Level: Application REF: p. 341, 343

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

23. 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

Feedback

A

These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

B

These are all indications of false labor; there is no indication that further assessment or observations are indicated.

C

The patient will probably be discharged, but there is no indication that a sedative is needed.

D

The situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 346

OBJ: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

24. The nurse auscultates the fetal heart rate (FHR) and determines a rate of 152. Which nursing intervention is appropriate?

a.

Inform the mother that the rate is normal.

b.

Reassess the FHR in 5 minutes because the rate is too high.

c.

Report the FHR 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

Feedback

A

The FHR is within the normal range, so no other action is indicated at this time.

B

The FHR is within the expected range; reassessment should occur, but not in 5 minutes.

C

The FHR is within the expected range; no further action is necessary at this point.

D

The sex of the baby cannot be determined by the FHR.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 320-321

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

25. A laboring woman is lying in the supine position. The most appropriate nursing action is to

a.

Ask her to turn to one side.

b.

Elevate her feet and legs.

c.

Take her blood pressure.

d.

Determine if fetal tachycardia is present.

ANS: A

Feedback

A

The womans supine position may cause the heavy uterus to compress her inferior vena cava, reducing blood return to her heart and reducing placental blood flow. This problem is relieved by having her turn onto her side.

B

Elevating her legs will not relieve the pressure from the inferior vena cava.

C

This position may produce hypotension in the woman, but the action should be to prevent this from happening, not to assess for the problem.

D

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 319

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

26. What finding should the nurse recognize as being associated with fetal compromise?

a.

Active fetal movements

b.

Contractions lasting 90 seconds

c.

FHR in the 140s

d.

Meconium-stained amniotic fluid

ANS: D

Feedback

A

Active fetal movement is an expected occurrence.

B

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.

C

Expected FHR range is from 120 to 160.

D

When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 344

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

27. During the active phase of labor, the FHR of a low-risk patient should be assessed every

a.

15 minutes

b.

30 minutes

c.

45 minutes

d.

1 hour

ANS: B

Feedback

A

15-minute assessments are appropriate for a fetus at high risk.

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.

C

45-minute assessments during the active phase of labor is not frequent enough to monitor for complications.

D

1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 339 | Table 16-2

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

28. 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

Feedback

A

Birth of the head occurs when the station is +4. A 0 station indicates engagement.

B

Bloody show occurs throughout the labor process and is not an indication of an imminent birth.

C

A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth.

D

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: p. 332

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

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

a.

Fetal injury

b.

Discomfort

c.

Infection

d.

Perineal trauma

ANS: C

Feedback

A

Properly performed vaginal examinations should not cause fetal injury.

B

Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them.

C

Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus.

D

A properly performed vaginal examination should not cause perineal trauma.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 344

OBJ: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

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

a.

Normal and related to hyperventilation

b.

Common during the transition phase of labor

c.

A sign that she needs analgesia

d.

Indicative of abnormal labor

ANS: B

Feedback

A

Hyperventilation will produce signs of respiratory alkalosis.

B

The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability.

C

If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near.

D

This change of behavior is an expected occurrence during the transition phase.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 332

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

31. 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 Apgar score for this infant?

a.

7

b.

8

c.

9

d.

10

ANS: C

Feedback

A

The baby received 2 points for each of the categories except color. Since the infants hands and feet were blue this category is given a grade of 1.

B

The baby received 2 points for each of the categories except color. Since the infants hands and feet were blue this category is given a grade of 1.

C

The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue hands and feet.

D

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

PTS: 1 DIF: Cognitive Level: Application REF: p. 360 | Table 16-3

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

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

a.

Take the blood pressure.

b.

Massage the fundus.

c.

Notify the physician or nurse-midwife.

d.

Place the woman in Trendelenburg position.

ANS: B

Feedback

A

The blood pressure is an important assessment to determine the extent of blood loss, but it is not the top priority.

B

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.

C

Notification should occur after all nursing measures have been attempted with no favorable results.

D

Trendelenburg position is contraindicated for this woman at this point. This position does 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: Comprehension REF: p. 361 | Table 16-4

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

33. 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

Feedback

A

Rubbing the infant does stimulate crying, but it is not the main reason for drying the infant.

B

Drying the infant after birth does not remove all of the maternal blood.

C

Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss.

D

The main purpose of drying the infant is to prevent heat loss.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 359

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

34. The nurse notes that a woman who has given birth 1 hour ago is touching her infant with the fingertips and talking to him softly in high-pitched tones. On the basis of this observation, the nurse should

a.

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

b.

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

c.

Request a social service consult for psychosocial support.

d.

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

ANS: A

Feedback

A

Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant.

B

These are signs of normal attachment behavior; no other assessment is necessary at this point.

C

There is no indication at this point that social service consult is necessary. The signs are of normal attachment behavior.

D

The mother may be fatigued but is interacting with the infant in an expected manner.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 361

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

35. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mothers right side close to midline. What is the likely position of the fetus?

a.

ROA

b.

LSP

c.

RSA

d.

LOA

ANS: C

Feedback

A

Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. RO/A/ denotes a fetus that is positioned anteriorly in the right side of the maternal pelvis with the occiput as the presenting part.

B

Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. LSP describes a fetus that is positioned posteriorly in the left side of the pelvis with the sacrum as the presenting part.

C

Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RS/A/ is the correct three-letter abbreviation to indicate this fetal position.

D

Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. /A/ fetus that is LOA, would be positioned anteriorly in the left side of the pelvis with the occiput as the presenting part.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 325-326

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

36. To adequately care for a laboring woman, the nurse should know that the _____ stage of labor varies the most in length.

a.

First

b.

Second

c.

Third

d.

Fourth

ANS: A

Feedback

A

The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first pregnancy, the first stage of labor can take up to 20 hours.

B

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.

C

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour.

D

The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 329, 332

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

37. A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate labor is getting closer to starting. The nurse informs the woman that which of the following is a sign that labor may begin soon?

a.

Weight gain of 1.5 to 2 kg (3 to 4 lb)

b.

Increase in fundal height

c.

Urinary retention

d.

Surge of energy

ANS: D

Feedback

A

The woman may lose 0.5 to 1.5 kg, the result of water loss caused by electrolyte shifts, which in turn are caused by changes in the estrogen and progesterone levels.

B

When the fetus descends into the true pelvis (called lightening), the fundal height may decrease.

C

Urinary frequency may return before labor.

D

Women speak of having a burst of energy before labor.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 329

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

MULTIPLE RESPONSE

1. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. These are the four major factors that interact during normal childbirth. What are the four Ps?

a.

Powers

b.

Passage

c.

Position

d.

Passenger

e.

Psyche

ANS: A, B, D, E

Feedback

Correct

Powers: the two powers of labor are uterine contractions and pushing efforts. During the first stage of labor through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. Passage: the passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor, because bones and joints do not yield as readily to the forces of labor. Passenger: this is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. Psyche: the psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the womans ability to cope.

Incorrect

Position is not one of the four Ps.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 321

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

COMPLETION

1. Inquiring about past pregnancies is an important part of the nursing assessment. Women who have had a previous cesarean birth may request a trial of labor and a ______ delivery.

ANS:

VBAC

Although vaginal birth after cesarean is less common, it may be chosen for a variety of reasons. The nurse should be aware of the need for increased support of the woman in labor, and for complications that may occur.

PTS: 1 DIF: Cognitive Level: Application REF: p. 337 | Table 16-2

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

TRUE/FALSE

1. Occasionally a woman arrives at the intrapartum unit ready to give birth. Bearing down, grunting, or stating something like the babys coming should direct the nurse to advise the client, Do not push, pant, and blow until the physician arrives. Is this statement true or false?

ANS: F

The nurses priority is to prevent or reduce injury to mother and infant if delivery is imminent. The emergency delivery kit should be obtained and preparation made for immediate delivery. An abbreviated assessment should be completed in order to obtain the mothers name, that of the support partner, and her care provider. Estimated date of delivery, allergies, and prenatal care are also important information. If time allows, maternal vital signs should be done, as well as a fetal assessment. After delivery, the priority is to maintain the infants airway and temperature.

PTS: 1 DIF: Cognitive Level: Application REF: p. 353 | Box 16-1

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

2. The woman in labor should be encouraged to use the Valsalva maneuver (holding ones breath and tightening abdominal muscles) for pushing during the second stage. Is this statement true or false?

ANS: F

The woman should actually be discouraged from using the Valsalva maneuver. This activity increases intrathoracic pressure, reduces venous return, and increases venous pressure. During the Valsalva maneuver, fetal hypoxia may occur. The process is reversed when the woman takes a breath.

PTS: 1 DIF: Cognitive Level: Application REF: p. 348

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

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