Chapter 20 Processes and Stages of Labor and Birth My Nursing Test Banks

Olds Maternal-Newborn Nursing and Womens Health, 10e (Davidson)

Chapter 20 Processes and Stages of Labor and Birth

1) How would the nurse best analyze the results from a clients sonogram that shows the fetal shoulder as the presenting part?

1. Breech, transverse

2. Breech, longitudinal

3. Breech, frank

4. Vertex, transverse

Answer: 1

Explanation: 1. A shoulder presentation is one type of breech presentation, and is also called a transverse lie.

Page Ref: 449, 450

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

2) A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Android

2. Anthropoid

3. Gynecoid

4. Platypelloid

5. Lambdoidal suture

Answer: 1, 4

Explanation: 1. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely.

4. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely.

Page Ref: 446, 466

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships

1

Copyright 2016 Pearson Education, Inc.

between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

3) The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Woman at 7 cm, fetus in general flexion

2. Woman at 3 cm, fetus in longitudinal lie

3. Woman at 4 cm, fetus with transverse lie

4. Woman at 6 cm, fetus at -2 station, mild contractions

5. Woman at 5 cm, fetal presenting part is right shoulder

Answer: 3, 4, 5

Explanation: 3. A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the womans spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor.

4. Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part.

5. When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part.

Page Ref: 448, 449, 450, 451

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

2

Copyright 2016 Pearson Education, Inc.

4) The charge nurse has received the shift change report. Which client requires immediate intervention?

1. Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes

2. Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation

3. Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge

4. Woman at 3 cm screaming in fear because her mother died during childbirth

Answer: 4

Explanation: 4. This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority.

Page Ref: 453, 454

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. C. 6. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that reflects high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Describe the physiologic and psychosocial changes that are indicative of the maternal progress during each of the stages of labor.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

5) Premonitory signs of labor include which of the following?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Braxton Hicks contractions

2. Cervical softening and effacement

3. Weight gain

4. Rupture of membranes

5. Sudden loss of energy

Answer: 1, 2, 4

Explanation: 1. A premonitory sign of labor includes Braxton Hicks contractions.

2. A premonitory sign of labor includes cervical softening and effacement.

4. A premonitory sign of labor includes rupture of membranes.

Page Ref: 456

Cognitive Level: Understanding

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment

3

Copyright 2016 Pearson Education, Inc.

Learning Outcome: 4 Discuss premonitory signs of labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

6) A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor?

1. Second phase

2. Latent phase

3. Active phase

4. Transition phase

Answer: 2

Explanation: 2. In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions.

Page Ref: 458

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

4

Copyright 2016 Pearson Education, Inc.

7) The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. What is the nurses best response to the client?

1. Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress.

2. When your perineal body thins out, your cervix will begin to dilate much faster than it is now.

3. What did you expect? Youve only had contractions for a few hours. Labor takes time.

4. The hormones that cause labor to begin are just getting to be at levels that will change your cervix.

Answer: 1

Explanation: 1. With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls.

Page Ref: 455

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Quality and Safety: Encourage patients and families to communicate their observations and concerns regarding safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

5

Copyright 2016 Pearson Education, Inc.

8) A woman who is 40 weeks pregnant calls the labor suite to ask whether she should be evaluated. Which statements by the client indicate she is likely in labor?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. The contractions are 5-20 minutes apart.

2. I had pink discharge on the toilet paper.

3. I have had cramping for the past 3-4 hours.

4. The contractions start in my back and then go to my abdomen and are very intense.

5. The contractions hurt more when I walk.

Answer: 4, 5

Explanation: 4. This is a sign of true labor. The contractions increase in duration and intensity and begin in the back and radiate around to the abdomen.

5. It is a sign of true labor when the client is unable to walk during the contraction.

Page Ref: 457

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

9) To identify the duration of a contraction, the nurse would do which of the following?

1. Start timing from the beginning of one contraction to the completion of the same contraction.

2. Time between the beginning of one contraction and the beginning of the next contraction.

3. Palpate for the strength of the contraction at its peak.

4. Time from the beginning of the contraction to the peak of the same contraction.

Answer: 1

Explanation: 1. The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction.

Page Ref: 453

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Describe the physiology of labor.

6

Copyright 2016 Pearson Education, Inc.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

10) The client at 40 weeks gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?

1. Unless you have pain with urination, we dont need to worry about it.

2. These symptoms usually mean the babys head has descended further.

3. Come in for an appointment today and well check everything out.

4. This might indicate that the baby is no longer in a head-down position.

Answer: 2

Explanation: 2. This is the best response because it most directly addresses what the client has reported.

Page Ref: 456

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4 Discuss premonitory signs of labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

11) The client at 39 weeks gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make?

1. You shouldnt work so much at this point in pregnancy.

2. What you are describing is not commonly experienced in the last weeks.

3. Your body may be telling you it is going into labor soon.

4. If the bladder pressure continues, come in to the clinic tomorrow.

Answer: 3

Explanation: 3. One of the premonitory signs of labor is lightening: The fetus begins to settle into the pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing.

Page Ref: 456

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Discuss premonitory signs of labor.

7

Copyright 2016 Pearson Education, Inc.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

8

Copyright 2016 Pearson Education, Inc.

12) A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and that over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following?

1. Engagement

2. Lightening

3. Molding

4. Braxton Hicks contractions

Answer: 2

Explanation: 2. Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet.

Page Ref: 456

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Discuss premonitory signs of labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

9

Copyright 2016 Pearson Education, Inc.

13) A client who is having false labor most likely would have which of the following?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Contractions that do not intensify while walking

2. An increase in the intensity and frequency of contractions

3. Progressive cervical effacement and dilatation

4. Pain in the abdomen that does not radiate

5. Contractions that lessen with rest and warm tub baths

Answer: 1, 4, 5

Explanation: 1. True labor contractions intensify while walking.

4. True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen.

5. In true labor, contractions do not lessen with rest and warm tub baths.

Page Ref: 457

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5 Differentiate between false and true labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

10

Copyright 2016 Pearson Education, Inc.

14) The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include?

1. True labor contractions begin in the back and sweep toward the front.

2. False labor often feels like abdominal tightening, or balling up.

3. True labor can be diagnosed only if cervical change occurs.

4. False labor contractions do not increase in intensity or duration.

Answer: 3

Explanation: 3. Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilatation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilatation.

Page Ref: 457

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5 Differentiate between false and true labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

11

Copyright 2016 Pearson Education, Inc.

15) The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor most likely will include which of the following?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Contractions that do not intensify while walking

2. An increase in the intensity and frequency of contractions

3. Progressive cervical effacement and dilatation

4. Pain in the abdomen that does not radiate

5. Contractions are at regular intervals

Answer: 1, 4

Explanation: 1. True labor contractions intensify while walking.

4. The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen.

Page Ref: 457

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5 Differentiate between false and true labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

12

Copyright 2016 Pearson Education, Inc.

16) A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor?

1. Active

2. Latent

3. Transition

4. Fourth

Answer: 3

Explanation: 3. The transition phase begins with 8 cm to 10 cm of dilatation, and contractions become more frequent, are longer in duration, and increase in intensity.

Page Ref: 458

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

17) A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor?

1. Active

2. Transition

3. Latent

4. Second

Answer: 2

Explanation: 2. During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety.

Page Ref: 458

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

13

Copyright 2016 Pearson Education, Inc.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

18) The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond?

1. In normal labor, as the uterine contractions become stronger, they usually also become less frequent.

2. In normal labor, as the uterine contractions become stronger, they usually also become less painful.

3. In normal labor, as the uterine contractions become stronger, they usually also become longer in duration.

4. In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration.

Answer: 3

Explanation: 3. During the active and transition phases, contractions become more frequent, are longer in duration, and increase in intensity.

Page Ref: 458

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly or cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

14

Copyright 2016 Pearson Education, Inc.

19) Four minutes after the birth of a baby, there is a sudden gush of blood from the mothers vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first?

1. Place the client in McRoberts position.

2. Watch for the emergence of the placenta.

3. Prepare for the delivery of an undiagnosed twin.

4. Place the client in a supine position.

Answer: 2

Explanation: 2. Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina.

Page Ref: 459

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

15

Copyright 2016 Pearson Education, Inc.

20) A nurse needs to evaluate the progress of a womans labor. The nurse obtains the following data: cervical dilatation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues?

1. Cervical dilatation 6 cm

2. Mild contraction intensity

3. Contraction frequency every 5 minutes

4. Contraction duration 30-40 seconds

Answer: 1

Explanation: 1. Cervical dilatation of 6 cm indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 cm and contractions and pain intensify.

Page Ref: 458

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

16

Copyright 2016 Pearson Education, Inc.

21) The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Bulging perineum

2. Increased bloody show

3. Spontaneous rupture of the membranes

4. Uncontrollable urge to push

5. Inability to breathe through contractions

Answer: 1, 2, 4

Explanation: 1. As the fetal head continues its descent, the perineum begins to bulge, flatten, and move anteriorly.

2. Bloody show increases as a woman enters the second stage of labor.

4. As the fetal head descends, the woman has the urge to push because of pressure of the fetal head on the sacral and obturator nerves.

Page Ref: 458

Cognitive Level: Evaluating

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

17

Copyright 2016 Pearson Education, Inc.

22) The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Maternal exhaustion

2. Cervical edema

3. Tearing and bruising of the cervix

4. Enhanced perineal thinning

5. Having to perform an episiotomy

Answer: 1, 2, 3

Explanation: 1. If the cervix is not completely dilated, maternal exhaustion can occur.

2. If the cervix is not completely dilated, cervical edema can occur.

3. If the cervix is not completely dilated, tearing and bruising of the cervix can occur.

Page Ref: 453

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Describe the physiologic and psychosocial changes that are indicative of the maternal progress during each of the stages of labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

18

Copyright 2016 Pearson Education, Inc.

23) The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important?

1. Leave the client alone so she can rest.

2. Ask the family to take a coffee-and-snack break.

3. Encourage the client to have an epidural for pain.

4. Reassure the client that she will not be left alone.

Answer: 4

Explanation: 4. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time.

Page Ref: 458

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

19

Copyright 2016 Pearson Education, Inc.

24) During the fourth stage of labor, the clients assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse?

1. Turn the client onto her left side.

2. Place the bed in Trendelenburg position.

3. Massage the fundus.

4. Continue to monitor.

Answer: 4

Explanation: 4. The clients assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia.

Page Ref: 459, 461

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

25) The nurse has just palpated a laboring womans contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as?

1. Weak

2. Mild

3. Moderate

4. Strong

Answer: 4

Explanation: 4. Strong intensity exists when the uterine wall cannot be indented.

Page Ref: 453

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Describe the physiologic and psychosocial changes that are indicative of the maternal progress during each of the stages of labor.

MNL LO: 3.1.2 Compare and contrast the theories of labor onset and the physiology of labor.

20

Copyright 2016 Pearson Education, Inc.

26) The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client?

1. Client at 5 cm requesting labor epidural analgesia

2. Client whose cervix remains at 6 cm for 4 hours

3. Client who has developed nausea and vomiting

4. Client requesting her partner to stay with her

Answer: 2

Explanation: 2. Average cervical change in the active phase of the first stage of labor is 1.2 cm/hour; thus, this clients lack of cervical change is unexpected, and should be reported to the supervisor.

Page Ref: 458

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: II. B. 9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

27) Which client requires immediate intervention by the labor and delivery nurse?

1. Client at 8 cm, systolic blood pressure has increased 35 mm Hg

2. Client who delivered 1 hour ago with WBC of 50,000

3. Client at 5 cm with a respiratory rate of 22 between contractions

4. Client in active labor with polyuria

Answer: 2

Explanation: 2. The white blood cell (WBC) count increases to 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification.

Page Ref: 463

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8 Summarize maternal systemic responses to labor.

MNL LO: 3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

21

Copyright 2016 Pearson Education, Inc.

28) The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor?

1. Increased pulse

2. Elevated blood pressure

3. Muscle tension

4. Increased respirations

Answer: 3

Explanation: 3. It is important for the woman to relax each part of her body. Be alert for signs of muscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process.

Page Ref: 444

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8 Summarize maternal systemic responses to labor.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

29) While caring for a client in labor, the nurse notices during a vaginal exam that the fetuss head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be?

1. Flexion, extension, restitution, external rotation, and expulsion

2. Expulsion, external rotation, and restitution

3. Restitution, flexion, external rotation, and expulsion

4. Extension, restitution, external rotation, and expulsion

Answer: 4

Explanation: 4. The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

Page Ref: 459

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases.

22

Copyright 2016 Pearson Education, Inc.

MNL LO: 3.1.3 Discuss the phases and stages of labor including factors that affect labor progress.

30) When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are what?

1. Both are approximately the same size

2. Both close within 12 months of birth

3. Both are used in labor to identify station

4. Both allow for assessing the status of the newborn after birth

Answer: 4

Explanation: 4. The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth.

Page Ref: 447

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

31) The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position?

1. Right-acromion-dorsal-anterior

2. Right-sacrum-transverse

3. Occiput anterior

4. Posterior position

Answer: 3

Explanation: 3. The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally.

Page Ref: 451

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

23

Copyright 2016 Pearson Education, Inc.

32) The midwife performs a vaginal exam and determines that the fetal head is at a -2 station. What does this indicate to the nurse about the birth?

1. The birth is imminent.

2. The birth is likely to occur in 1-2 hours.

3. The birth will occur later in the shift.

4. The birth is difficult to predict.

Answer: 4

Explanation: 4. A -2 station means that the fetus is 2 cm above the ischial spines. The ischial spines as a landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. With the fetuss head that high in the pelvis, it is difficult to predict when birth will occur.

Page Ref: 450

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

24

Copyright 2016 Pearson Education, Inc.

33) Childbirth preparation offers several advantages including which of the following?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. It helps a pregnant woman and her support person understand the choices in the birth setting.

2. It promotes awareness of available options.

3. It provides tools for a pregnant woman and her support person to use during labor and birth.

4. Women who receive continuous support during labor require more analgesia, and have more cesarean and instrument births.

5. Each method has been shown to shorten labor.

Answer: 1, 2, 3, 5

Explanation: 1. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth.

2. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth.

3. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth.

5. Childbirth preparation offers several advantages. Each method has been shown to shorten labor.

Page Ref: 443

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Compare methods of childbirth preparation.

25

Copyright 2016 Pearson Education, Inc.

34) The nurse determines that a client is carrying her fetus in the vertical (longitudinal) lie. The nurses judgment should be questioned if the fetal presenting part is which of the following?

Note: Credit will be given only for all correct choices and no incorrect choices.

Select all that apply.

1. Sacrum

2. Left arm

3. Mentum

4. Left scapula

5. Right scapula

Answer: 2, 4, 5

Explanation: 2. A fetus with an arm presenting is likely in a horizontal lie.

4. A fetus with a left scapula presenting is in a horizontal lie.

5. A fetus with a right scapula presenting is in a horizontal lie.

Page Ref: 449

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2 Examine the five critical factors that affect the labor process.

MNL LO: 3.3.1 Describe the five processes of labor.

Leave a Reply