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

Lowdermilk: Maternity & Womens Health Care, 10th Edition

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

Test Bank

MULTIPLE CHOICE

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

a.

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

b.

My bag of waters just broke.

c.

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

d.

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

ANS: C

Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.

Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor.

Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor.

The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.

DIF: Cognitive Level: Application REF: 434

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

a.

Tell the woman to stay home until her membranes rupture

b.

Emphasize that food and fluid intake should stop

c.

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

d.

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

ANS: D

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.

The initial nursing activity should be to gather data about the womans status. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.

Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.

DIF: Cognitive Level: Application REF: 434

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

a.

Intrauterine infection

b.

Hemorrhage

c.

Precipitous labor

d.

Supine hypotension

ANS: A

When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis.

Rupture of membranes (ROM) is not associated with fetal or maternal bleeding.

Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor.

ROM has no correlation with supine hypotension.

DIF: Cognitive Level: Comprehension REF: 448

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning, Diagnosis

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

a.

Notify the womans primary health care provider immediately

b.

Prepare to administer an oxytocic to stimulate uterine activity

c.

Document the findings because they reflect the expected contraction pattern for the active phase of labor

d.

Prepare the woman for the onset of the second stage of labor

ANS: C

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. Additionally 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 adequate active labor.

This labor pattern indicates that the woman is in active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

DIF: Cognitive Level: Application REF: 439

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

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

a.

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

b.

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

c.

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

d.

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

ANS: C

The nurse or primary 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: Application REF: 445

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

a.

Dilation of the cervix

b.

Descent of the fetus

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.

Descent of the fetus, or engagement, may occur before labor.

Rupture of membranes may occur with or without the presence of labor.

Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.

DIF: Cognitive Level: Comprehension REF: 434

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment, Diagnosis

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

a.

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

b.

Perform the examination with the woman in the supine position

c.

Wear two clean gloves for each examination

d.

Discuss the findings with the woman and her partner

ANS: D

The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider.

A vaginal examination should be performed only when indicated by the status of the woman and her fetus.

The woman should be positioned 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: Application REF: 446

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment

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

a.

Prepare the woman for imminent birth

b.

Notify the womans primary health care provider

c.

Document the characteristics of the fluid

d.

Assess the fetal heart rate and pattern

ANS: D

The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented.

Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent.

The nurse may notify the primary 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: Application REF: 448

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

9. The nurse should assist the laboring woman into a hands-and-knees position when:

a.

The occiput of the fetus is in a posterior position

b.

The fetus is at or above the ischial spines

c.

The fetus is in a vertex presentation

d.

The membranes rupture

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 occurs 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: Comprehension REF: 455

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

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

a.

Experiences a strong urge to bear down

b.

Shows perineal bulging

c.

Feels tired yet relieved that the worst is over

d.

Shows an increase in bright red bloody show

ANS: C

Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because the worst is over. The woman may be very quiet during this phase.

During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions.

Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage.

An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

DIF: Cognitive Level: Comprehension REF: 458

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Evaluation

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

a.

The amniotic membranes rupture

b.

The cervix cannot be felt during a vaginal examination

c.

The woman experiences a strong urge to bear down

d.

The presenting part is below the ischial spines

ANS: C

During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down.

Rupture of membranes (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 part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm dilation.

DIF: Cognitive Level: Comprehension REF: 458

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

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

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: Comprehension REF: 439

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

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, support respiratory effort, and prevent cold stress by drying the newborn and covering 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 partner or the mother the infant.

DIF: Cognitive Level: Comprehension REF: 470

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

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

a.

Relieve pain

b.

Stimulate uterine contraction

c.

Prevent infection

d.

Facilitate rest and relaxation

ANS: B

Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor.

Oxytocics are not used to treat pain.

Oxytocics do not prevent infection.

Oxytocics do not facilitate rest and relaxation.

DIF: Cognitive Level: Knowledge REF: 471

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning, Implementation

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

a.

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

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, regular contractions, 4 to 7 cm dilation, and a duration of 3 to 6 hours.

The latent phase is characterized by mild to moderate, irregular contractions, dilation up to 3 cm, brownish to pale pink mucus, and a duration of 6 to 8 hours.

No official lull phase exists in the first stage.

The transition phase is characterized by strong to very strong, regular contractions, 8 to 10 cm dilation, and a duration of 20 to 40 minutes.

DIF: Cognitive Level: Comprehension REF: 434

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

16. With regard to the procedures and criteria for admitting a woman to the hospital labor unit, nurses should be aware that:

a.

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

b.

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

c.

Her weight gain is calculated to determine whether she is at greater risk for complications

d.

The nurse should listen politely to the womans previous birthing experiences but should keep in mind that each birth is a unique experience

ANS: C

Increasing numbers of women are overweight or obese. Excessive size can make nursing care during labor and birth more difficult and places the woman at risk for complications such as operative birth, infection, and blood clots.

According to EMTALA, a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise.

A woman may have anyone she wishes present for her support.

The details of previous birthing experiences are important. Not only the mechanics of labor and the outcome but also the womans perceptions can influence her present attitude.

DIF: Cognitive Level: Comprehension REF: 435

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

17. As part of the physical examination component of assessment, Leopold maneuvers are used to help identify all of the following except:

a.

The gender of the fetus

b.

The number of fetuses

c.

The fetal lie and attitude

d.

The degree of the presenting parts descent into the pelvis

ANS: A

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

Leopold maneuvers help identify the number of fetuses.

Leopold maneuvers assist the nurse in determining the fetal lie and attitude.

Leopold maneuvers can be used to ascertain the presenting parts degree of descent into the pelvis.

DIF: Cognitive Level: Knowledge REF: 443

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

a.

Usually directly over the fetal abdomen

b.

In a vertex position, heard above the mothers umbilicus

c.

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

d.

In a breech position, heard below the mothers umbilicus

ANS: C

Nurses should be prepared for the shift.

The PMI of the FHR usually is directly over the fetal back.

In a vertex position, it is heard below the mothers umbilicus.

In a breech position, it is heard above the mothers umbilicus.

DIF: Cognitive Level: Comprehension REF: 444

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

a.

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

b.

IV fluids usually are necessary to ensure that the laboring woman stays hydrated

c.

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

d.

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

ANS: A

Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration.

Routine IV fluids during labor are unlikely to be beneficial and may be harmful.

Routine use of an enema is at best ineffective and may be harmful.

Having the urge to defecate followed by the birth of her fetus is true for a multiparous woman but not for a first-timer.

DIF: Cognitive Level: Comprehension REF: 451

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

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

a.

The woman has a sudden episode of vomiting

b.

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

c.

Bloody show increases

d.

The woman involuntarily tries to bear down

ANS: B

The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.

Sudden vomiting is a suggestion of second-stage labor; however, the only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.

Bloody show increases during the second stage of labor; however, the inability to feel the cervix is an objective sign that the second stage has begun.

The urge to bear down is a suggestion of second-stage labor. The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.

DIF: Cognitive Level: Knowledge REF: 458

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

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

a.

The Ritgen maneuver

b.

Fundal pressure

c.

The lithotomy position

d.

The De Lee apparatus

ANS: A

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: Knowledge REF: 467

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

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

a.

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

b.

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

c.

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

d.

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

ANS: D

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

This woman is at low risk for either damaging lacerations or an episiotomy. The client 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. This puts the client at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy.

The fact that this woman 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: Application REF: 470

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Diagnosis

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

a.

The placenta eventually detaches itself from a flaccid uterus

b.

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

c.

It is important that the dark, roughened maternal surface of the placenta 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 hemorrhage.

DIF: Cognitive Level: Comprehension REF: 471

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning, Implementation

24. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-oz boy after augmentation of labor with oxytocin (Pitocin). She puts on her call light and asks for her nurse right away, stating Im bleeding a lot. The most likely cause of postpartum hemorrhage in this woman is:

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. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony.

Although retained placental fragments may cause postpartum hemorrhage, this typically is detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman.

Although unrepaired vaginal lacerations may cause bleeding, they typically occur in the period immediately after birth.

Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically is detected after 24 hours postpartum.

DIF: Cognitive Level: Analysis REF: 474

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

25. In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:

a.

Has recovered from epidural or spinal anesthesia

b.

Has hidden bleeding underneath her

c.

Has regained some flexibility

d.

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, she likely has recovered from the epidural or spinal anesthesia.

It is always important to assess the client for bleeding beneath her buttocks prior to discharge from the recovery room; 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 in order to evaluate if the client has recovered from spinal anesthesia, not to determine if she is a candidate for early discharge.

DIF: Cognitive Level: Comprehension REF: 475

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

TOP: Nursing Process: Evaluation

26. 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. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help 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: Comprehension REF: 438

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

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

a.

Mexico

b.

China

c.

Iran

d.

India

ANS: A

A woman from Mexico may be stoic about discomfort until the second stage, at which time she will request pain relief. Fathers and female relatives are usually in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well.

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. 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 present. Natural childbirth methods are preferred.

DIF: Cognitive Level: Application REF: 440

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Planning

MULTIPLE RESPONSE

1. Emergency conditions during labor that require immediate nursing intervention can arise with startling speed. Examples of such emergencies include (choose all that apply):

a.

Nonreassuring or abnormal fetal heart rate (FHR) pattern

b.

Inadequate uterine relaxation

c.

Vaginal bleeding

d.

Infection

e.

Prolapse of the cord

ANS: A, B, C, D, 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.

DIF: Cognitive Level: Comprehension REF: 459

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning, Implementation

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

a.

Presence of companions

b.

Clothing to be worn

c.

Care and handling of the newborn

d.

Medical interventions

e.

Environmental modifications

ANS: A, B, C, D, E

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. Couples can visit www.childbirth.org for an interactive birth plan to assist them in preparing for their birth.

DIF: Cognitive Level: Application REF: 438

OBJ: Client Needs: Physiologic and Psychologic Integrity

TOP: Nursing Process: Planning

COMPLETION

1. The progress of labor can be verified effectively through use of a chart that plots cervical dilation and station. This chart is called a(n) ____________________.

ANS:

Partogram

This type of graphic charting assists in early identification of deviations from expected labor patterns.

DIF: Cognitive Level: Comprehension REF: 445

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

2. Nurses should not use ____________________ pressure to facilitate birth, because no standard techniques are available for this maneuver, and no legal, professional, or regulatory standards exist for its use.

ANS:

Fundal

Historically, fundal pressure has been used when the administration of analgesia and anesthesia decreased the womans ability to push during birth, in cases of shoulder dystocia and when second-stage fetal bradycardia is present. Use of fundal pressure is no longer recommended because there is no evidence related to its effectiveness in facilitating a safe vaginal birth.

DIF: Cognitive Level: Comprehension REF: 467

OBJ: Client Needs: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

3. A ____________-degree perineal laceration continues through the anal sphincter muscle.

ANS:

Third

Third- and fourth-degree lacerations must be carefully repaired so that the woman retains fecal continence.

DIF: Cognitive Level: Comprehension REF: 471

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Diagnosis

4. The period encompassing the first 1 to 2 hours after birth often is referred to as the ____________________ stage of labor.

ANS:

Fourth

This is a crucial time for mother and newborn. Both are not only recovering from the physical part of birth but are also becoming familiar with each other and additional family members.

DIF: Cognitive Level: Comprehension REF: 473

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

TRUE/FALSE

1. A woman from out of state is visiting her relatives for the holidays. She presents at your facility in labor but does not have a copy of her prenatal records. The nurse would like to contact the womans health care provider to obtain these records. Because the woman is in active labor it is not necessary for the nurse to obtain written consent for the transfer of these records. Is this statement true or false?

ANS: F

According to the Health Insurance Portability and Accountability Act (HIPAA) the woman must give permission for other persons to be involved in the exchange of information regarding her care.

DIF: Cognitive Level: Application REF: 435

OBJ: Client Needs: Safe and Effective Care Environment

TOP: Nursing Process: Planning

2. 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 tightening the abdominal muscles. During the second stage of labor, when the woman is ready to push, this is considered the optimal method to enhance movement of the fetus down the birth canal. Is this statement true or false?

ANS: F

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: Comprehension REF: 464

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

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