Chapter 19: Nursing Care of the Family During Labor and Birth My Nursing Test Banks

Chapter 19: Nursing Care of the Family During Labor and Birth

Lowdermilk: Maternity & Womens Health Care, 11th Edition

MULTIPLE CHOICE

1. Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor?

a.

I passed some thick, pink mucus when I urinated this morning.

b.

My bag of waters just broke.

c.

The contractions in my uterus are getting stronger and closer together.

d.

My baby dropped, and I have to urinate more frequently now.

ANS: C

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

DIF: Cognitive Level: Understand REF: p. 431

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

2. When a nulliparous woman telephones the hospital to report that she is in labor, what guidance should the nurse provide or information should the nurse obtain?

a.

Tell the woman to stay home until her membranes rupture.

b.

Emphasize that food and fluid intake should stop.

c.

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

d.

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

ANS: D

Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data. 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 client may be instructed to stay home until the uterine contractions become strong and regular. Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview. 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 client or her primary health care provider.

DIF: Cognitive Level: Apply REF: p. 434

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

3. The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication?

a.

Intrauterine infection

b.

Hemorrhage

c.

Precipitous labor

d.

Supine hypotension

ANS: A

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

DIF: Cognitive Level: Apply REF: p. 444

TOP: Nursing Process: Planning | Nursing Process: Diagnosis

MSC: Client Needs: Physiologic Integrity

4. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next?

a.

Immediately notify the womans primary health care provider.

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

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 documents these findings in the clients medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually 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: Apply REF: p. 436

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

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

a.

Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips

b.

Determining the frequency by timing from the end of one contraction to the end of the next contraction

c.

Evaluating the intensity by pressing the fingertips into the uterine fundus

d.

Assessing uterine contractions every 30 minutes throughout the first stage of labor

ANS: C

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

DIF: Cognitive Level: Apply REF: pp. 440-441

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

6. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?

a.

Dilation of the cervix

b.

Descent of the fetus to 2 station

c.

Rupture of the amniotic membranes

d.

Increase in bloody show

ANS: A

The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor, indicates that the woman is in true labor. Engagement and descent of the fetus are not synonymous and may occur before labor. ROM may occur with or without the presence of labor. Bloody show may indicate a slow, progressive cervical change (e.g., effacement) in both true and false labor.

DIF: Cognitive Level: Understand REF: p. 431

TOP: Nursing Process: Assessment | Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

7. The nurse performs a vaginal examination to assess a clients labor progress. Which action should the nurse take next?

a.

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

b.

Perform the examination with the woman in the supine position.

c.

Wear two clean gloves for each examination.

d.

Discuss the findings with the woman and her partner.

ANS: D

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

DIF: Cognitive Level: Apply REF: p. 444

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

8. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurses highest priority in this situation?

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 (FHR) and pattern.

ANS: D

The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the ROM to ascertain fetal well-being, and the findings should be documented. The ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary health 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. 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.

DIF: Cognitive Level: Apply REF: p. 444

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

9. Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position?

a.

Occiput of the fetus is in a posterior position.

b.

Fetus is at or above the ischial spines.

c.

Fetus is in a vertex presentation.

d.

Membranes have ruptured.

ANS: A

The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position. Many women experience the irresistible urge to push when the fetus is at the level of the ischial spines. In some cases, this urge is felt before the woman is fully dilated. The woman should be instructed not to push until complete cervical dilation has occurred. No one position is correct for childbirth. The two most common positions assumed by women are the sitting and side-lying positions. The woman may be encouraged into a hands-and-knees position if the umbilical cord prolapsed when the membranes ruptured.

DIF: Cognitive Level: Apply REF: p. 449

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

10. A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior?

a.

A nulliparous woman will experience a strong urge to bear down.

b.

Perineal bulging will show.

c.

A nulliparous woman will remain quiet with her eyes closed between contractions.

d.

The amount of bright red bloody show will increase.

ANS: C

The woman is able to relax and close her eyes between contractions as the fetus passively descends. The woman may be very quiet during this phase. During the latent phase of the second stage of labor, the urge to bear down is often absent or only slight during the acme of the contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

DIF: Cognitive Level: Understand REF: p. 454 TOP: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity

11. Which clinical finding indicates that the client has reached the second stage of labor?

a.

Amniotic membranes rupture.

b.

Cervix cannot be felt during a vaginal examination.

c.

Woman experiences a strong urge to bear down.

d.

Presenting part of the fetus is below the ischial spines.

ANS: C

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

DIF: Cognitive Level: Understand REF: p. 454 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

12. Through a vaginal examination, the nurse determines that a woman is 4 cm dilated. The external fetal monitor shows uterine contractions every to 4 minutes. The nurse reports this as what stage of labor?

a.

First stage, latent phase

b.

First stage, active phase

c.

First stage, transition phase

d.

Second stage, latent phase

ANS: B

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

DIF: Cognitive Level: Understand REF: p. 436

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

13. What is the most critical nursing action in caring for the newborn immediately after the birth?

a.

Keeping the airway clear

b.

Fostering parent-newborn attachment

c.

Drying the newborn and wrapping the infant in a blanket

d.

Administering eye drops and vitamin K

ANS: A

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

DIF: Cognitive Level: Apply REF: p. 464

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

14. What is the rationale for the administration of an oxytocic (e.g., Pitocin, Methergine) after expulsion of the placenta?

a.

To relieve pain

b.

To stimulate uterine contraction

c.

To prevent infection

d.

To facilitate rest and relaxation

ANS: B

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

DIF: Cognitive Level: Remember REF: p. 466

TOP: Nursing Process: Planning | Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

15. Which description of the phases of the first stage of labor is most accurate?

a.

Latent: mild, regular contractions; no dilation; bloody show

b.

Active: moderate, regular contractions; 4 to 7 cm dilation

c.

Lull: no contractions; dilation stable

d.

Transition: very strong but irregular contractions; 8 to 10 cm dilation

ANS: B

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

DIF: Cognitive Level: Understand REF: p. 436 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

16. Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand?

a.

Client is considered to be in active labor when she arrives at the facility with contractions.

b.

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

c.

Children are not allowed on the labor unit.

d.

NonEnglish speaking client must bring someone to translate.

ANS: A

According to the Emergency Medical Treatment and Active Labor Act (EMTALA), a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise. A woman may have anyone she wishes present for her support. An interpreter must be provided by the hospital, either in person or by a telephonic service. Siblings of the new infant may be allowed at the delivery, depending on hospital policy and adequate preparation and supervision.

DIF: Cognitive Level: Understand REF: p. 432 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

17. Which component of the physical examination are Leopolds maneuvers unable to determine?

a.

Gender of the fetus

b.

Number of fetuses

c.

Fetal lie and attitude

d.

Degree of the presenting parts descent into the pelvis

ANS: A

Leopolds maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus cannot be determined by performing Leopolds maneuvers.

DIF: Cognitive Level: Remember REF: pp. 439, 440

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

18. Where is the point of maximal intensity (PMI) of the FHR located?

a.

Usually directly over the fetal abdomen

b.

In a vertex position, heard above the mothers umbilicus

c.

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

d.

In a breech position, heard below the mothers umbilicus

ANS: C

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

DIF: Cognitive Level: Understand REF: p. 440

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

19. The nurse should be aware of which information related to a womans intake and output during labor?

a.

Traditionally, 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 are usually 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 quickly follow.

ANS: A

Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. The routine use of an enema is, at best, ineffective and may be harmful. Having the urge to defecate followed by the birth of her fetus is true for a multiparous woman but not for a nulliparous woman.

DIF: Cognitive Level: Understand REF: p. 445 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

20. Which technique is an adequate means of controlling the birth of the fetal head during delivery in a vertex presentation?

a.

Ritgen maneuver

b.

Fundal pressure

c.

Lithotomy position

d.

De Lee apparatus

ANS: A

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

DIF: Cognitive Level: Remember REF: p. 464

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

21. Which collection of risk factors will most likely result in damaging lacerations, including episiotomies?

a.

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

b.

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

c.

Dark-skinned first-time mother who is going through a long labor

d.

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

ANS: D

Reddish-haired women have tissue that is less distensible than darker-skinned women and therefore may have less efficient healing. First-time mothers are also at greater risk, especially with breech births, long second-stage labors, or rapid labors during which the time for the perineum to stretch is insufficient. The rate of episiotomies is higher when obstetricians rather than midwives attend the births. The woman in the first scenario (a) is at low risk for either damaging lacerations or an episiotomy. She is multiparous, has dark skin, and is being attended by a midwife, who is less likely to perform an episiotomy. Reddish-haired women have tissue that is less distensible than that of darker-skinned women. Consequently, the client in the second scenario (b) is at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy. The fact that the woman in the third scenario (c) is experiencing a prolonged labor might increase her risk for lacerations. Fortunately, she is dark skinned, which indicates that her tissue is more distensible than that of fair-skinned women and therefore less susceptible to injury.

DIF: Cognitive Level: Apply REF: p. 465 TOP: Nursing Process: Diagnosis

MSC: Client Needs: Physiologic Integrity

22. Which statement concerning the third stage of labor is correct?

a.

The placenta eventually detaches itself from a flaccid uterus.

b.

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

c.

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

d.

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

ANS: B

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

DIF: Cognitive Level: Understand REF: p. 466

TOP: Nursing Process: Planning | Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

23. A 25-year-old gravida 3, para 2 client gave birth to a 9-pound, 7-ounce boy, 4 hours ago after augmentation of labor with oxytocin (Pitocin). She presses her call light, and asks for her nurse right away, stating Im bleeding a lot. What is the most likely cause of postpartum hemorrhaging in this client?

a.

Retained placental fragments

b.

Unrepaired vaginal lacerations

c.

Uterine atony

d.

Puerperal infection

ANS: C

This woman gave birth to a macrosomic infant after oxytocin augmentation. Combined with these risk factors, uterine atony is the most likely cause of bleeding 4 hours after delivery. Although retained placental fragments may cause postpartum hemorrhaging, it is typically detected within the first hour after delivery of the placenta and is not the most likely cause of the hemorrhaging in this woman. Although unrepaired vaginal lacerations may also cause bleeding, it typically occurs in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding that is, however, typically detected 24 hours postpartum.

DIF: Cognitive Level: Analyze REF: p. 466

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

24. In recovery, if a woman is asked to either raise her legs (knees extended) off the bed or flex her knees, and then place her feet flat on the bed and raise her buttocks well off the bed, the purpose of this exercise is to assess what?

a.

Recovery from epidural or spinal anesthesia

b.

Hidden bleeding underneath her

c.

Flexibility

d.

Whether the woman is a candidate to go home after 6 hours

ANS: A

If the numb or prickly sensations are gone from her legs after these movements, then she has likely recovered from the epidural or spinal anesthesia. Assessing the client for bleeding beneath her buttocks before discharge from the recovery is always important; however, she should be rolled to her side for this assessment. The nurse is not required to assess the woman for flexibility. This assessment is performed to evaluate whether the client has recovered from spinal anesthesia, not to determine if she is a candidate for early discharge.

DIF: Cognitive Level: Understand REF: p. 468 TOP: Nursing Process: Evaluation

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

25. A woman who has a history of sexual abuse may have a number of traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care?

a.

Tell the client to relax and that it wont hurt much.

b.

Limit the number of procedures that invade her body.

c.

Reassure the client that, as the nurse, you know what is best.

d.

Allow unlimited care providers to be with the client.

ANS: B

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

DIF: Cognitive Level: Understand REF: p. 435

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

26. As the United States and Canada continue to become more culturally diverse, recognizing a wide range of varying cultural beliefs and practices is increasingly important for the nursing staff. A client is from which country if she requests to have the babys father in attendance?

a.

Mexico

b.

China

c.

Iran

d.

India

ANS: A

Hispanic women routinely have fathers and female relatives 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. In China, fathers are usually not present. The side-lying position is preferred for labor and birth because it is believed that this will reduce trauma to the infant. In China, the client has a stoic response to pain. In Iran, the father will not be present. Female support persons and female health care providers are preferred. For many, a male caregiver is unacceptable. In India, the father is usually not present, but female relatives are usually in attendance. Natural childbirth methods are preferred.

DIF: Cognitive Level: Apply REF: p. 437 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

27. The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding ones breath with a closed glottis and a tightening of the abdominal muscles. When is it appropriate to instruct the client to use this maneuver?

a.

During the second stage to enhance the movement of the fetus

b.

During the third stage to help expel the placenta

c.

During the fourth stage to expel blood clots

d.

Not at all

ANS: D

The client should not be instructed to use this maneuver. This process stimulates the parasympathetic division of the autonomic nervous system and produces a vagal response (decrease in heart rate and blood pressure.) An alternative method includes instructing the client to perform open-mouth and open-glottis breathing and pushing.

DIF: Cognitive Level: Apply REF: p. 458

TOP: Nursing Process: Implementation

MSC: Client Needs: Physiologic and Psychologic Integrity

28. The first 1 to 2 hours after birth is sometimes referred to as what?

a.

Bonding period

b.

Third stage of labor

c.

Fourth stage of labor

d.

Early postpartum period

ANS: C

The first 2 hours of the birth are a critical time for the mother and her baby and is often called the fourth stage of labor. Maternal organs undergo their initial readjustment to a nonpregnant state. The third stage of labor lasts from the birth of the baby to the expulsion of the placenta. Bonding will occur over a much longer period, although it may be initiated during the fourth stage of labor.

DIF: Cognitive Level: Understand REF: p. 468

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

29. 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. Which instruction best describes these measures?

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

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

DIF: Cognitive Level: Comprehend REF: p. 449

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

30. 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. What is the nurses assessment of the situation?

a.

The placenta has separated.

b.

A cervical tear occurred during the birth.

c.

The woman is beginning to hemorrhage.

d.

Clots have formed in the upper uterine segment.

ANS: A

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

DIF: Cognitive Level: Understand REF: p. 467

TOP: Nursing Process: Assessment | Nursing Process: Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

31. After an emergency birth, the nurse encourages the woman to breastfeed her newborn. What is the primary purpose of this activity?

a.

To facilitate maternal-newborn interaction

b.

To stimulate the uterus to contract

c.

To prevent neonatal hypoglycemia

d.

To initiate the lactation cycle

ANS: B

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

DIF: Cognitive Level: Understand REF: p. 469

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

32. A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurses ideal response?

a.

Dont worry about it. Youll do fine.

b.

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

c.

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

d.

You can have an epidural. You wont feel anything.

ANS: B

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

DIF: Cognitive Level: Apply REF: p. 435 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

33. Which characteristic of a uterine contraction is not routinely documented?

a.

Frequency: how often contractions occur

b.

Intensity: strength of the contraction at its peak

c.

Resting tone: tension in the uterine muscle

d.

Appearance: shape and height

ANS: D

Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not routinely charted.

DIF: Cognitive Level: Remember REF: p. 440

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

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

a.

Admission to the hospital at the start of labor

b.

When accelerations of the FHR are noted

c.

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

d.

When membranes rupture

ANS: B

An accelerated FHR is a positive sign; therefore, a vaginal examination would not be necessary. A vaginal examination should be performed when the woman is admitted to the hospital, 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: Remember REF: p. 442

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

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

a.

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

b.

Active phase: Overwhelmingly strong contractions; Ferguson reflux activated; duration of 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 0; duration of 15 minutes

ANS: C

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

DIF: Cognitive Level: Understand REF: p. 454

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

36. A woman who is gravida 3 para 2 arrives on the intrapartum unit. What is the most important nursing assessment at this time?

a.

Contraction pattern, amount of discomfort, and pregnancy history

b.

FHR, maternal vital signs, and the womans nearness to birth

c.

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

d.

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

ANS: B

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

DIF: Cognitive Level: Apply REF: p. 460

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

37. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The FHR 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. What disposition would the nurse anticipate?

a.

Admitted and prepared for a cesarean birth

b.

Admitted for extended observation

c.

Discharged home with a sedative

d.

Discharged home to await the onset of true labor

ANS: D

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

DIF: Cognitive Level: Analyze REF: p. 431

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

38. A laboring woman is reclining in the supine position. What is the most appropriate nursing action at this time?

a.

Ask her to turn to one side.

b.

Elevate her feet and legs.

c.

Take her blood pressure.

d.

Determine whether fetal tachycardia is present.

ANS: A

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

DIF: Cognitive Level: Apply REF: p. 439

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

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

a.

Fetal head is felt at 0 station during vaginal examination.

b.

Bloody mucous discharge increases.

c.

Vulva bulges and encircles the fetal head.

d.

Membranes rupture during a contraction.

ANS: C

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

DIF: Cognitive Level: Analyze REF: p. 456

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

40. What is the primary rationale for the thorough drying of the infant immediately after birth?

a.

Stimulates crying and lung expansion

b.

Removes maternal blood from the skin surface

c.

Reduces heat loss from evaporation

d.

Increases blood supply to the hands and feet

ANS: C

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

DIF: Cognitive Level: Understand REF: p. 457

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

MULTIPLE RESPONSE

1. Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.)

a.

Nonreassuring or abnormal FHR pattern

b.

Inadequate uterine relaxation

c.

Vaginal bleeding

d.

Prolonged second stage

e.

Prolapse of the cord

ANS: A, B, C, E

A nonreassuring or abnormal FHR pattern, inadequate uterine relaxation, vaginal bleeding, infection, and cord prolapse all constitute an emergency during labor that requires immediate nursing intervention. A prolonged second stage of labor after the upper limits for duration is reached. This is 3 hours for nulliparous women and 2 hours for multiparous women.

DIF: Cognitive Level: Understand REF: pp. 453-454

TOP: Nursing Process: Planning | Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

2. Women who have participated in childbirth education classes often bring a birth plan with them to the hospital. Which items might this plan include? (Select all that apply.)

a.

Presence of companions

b.

Clothing to be worn

c.

Care and handling of the newborn

d.

Medical interventions

e.

Date of delivery

ANS: A, B, C, D

The presence of companions, clothing to be worn, care and handling of the newborn, medical interventions, and environmental modifications all might be included in the couples birth plan. Other items include the presence of nonessential medical personnel (students), labor activities such as the tub or ambulation, preferred comfort and relaxation methods, and any cultural or religious requirements. The expected date of delivery would not be part of a birth plan unless the client is scheduled for an elective cesarean birth.

DIF: Cognitive Level: Apply REF: p. 435 TOP: Nursing Process: Planning

MSC: Client Needs: Physiologic and Psychologic Integrity

MATCHING

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

a.

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

b.

Explain the findings to the client.

c.

Position the woman to prevent supine hypotension.

d.

Use sterile gloves and soluble gel for lubrication.

e.

Document findings and report to the health care provider.

f.

Cleanse the perineum and vulva, if necessary.

g.

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

1. Step 1

2. Step 2

3. Step 3

4. Step 4

5. Step 5

6. Step 6

7. Step 7

1. ANS: D DIF: Cognitive Level: Apply REF: p. 444

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

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

2. ANS: C DIF: Cognitive Level: Apply REF: p. 444

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

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

3. ANS: F DIF: Cognitive Level: Apply REF: p. 444

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

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

4. ANS: A DIF: Cognitive Level: Apply REF: p. 444

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

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

5. ANS: G DIF: Cognitive Level: Apply REF: p. 444

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

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

6. ANS: B DIF: Cognitive Level: Apply REF: p. 444

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

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

7. ANS: E DIF: Cognitive Level: Apply REF: p. 444

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

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

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