Chapter 22 The Family in Childbirth: Needs and Care My Nursing Test Banks

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

Chapter 22 The Family in Childbirth: Needs and Care

1) The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the clients back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client?

1. Fear/Anxiety related to discomfort of labor and unknown labor outcome

2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent

3. Coping: Family, Compromised, related to labor process

4. Knowledge, Deficient, related to lack of information about normal labor process and comfort measures

Answer: 2

Explanation: 2. The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor.

Page Ref: 509

Cognitive Level: Applying

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

Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1 Identify nursing diagnoses specific to the first, second, third, and fourth stages of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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2) A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor?

1. Latent phase

2. Active phase

3. Transition phase

4. Fourth stage

Answer: 3

Explanation: 3. The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense.

Page Ref: 516

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: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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3) Usually, the family is advised to arrive at the birth setting at the beginning of the active phase of labor or when which of the following occur?

Note: Credit will be given only if all correct and no incorrect choices are selected.

Select all that apply.

1. Rupture of membranes (ROM)

2. Increased fetal movement

3. Decreased fetal movement

4. Any vaginal bleeding

5. Regular, frequent uterine contractions (UCs)

Answer: 1, 3, 4, 5

Explanation: 1. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when the membranes rupture.

3. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there is decreased fetal movement.

4. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there is any vaginal bleeding.

5. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there are regular, frequent uterine contractions.

Page Ref: 509

Cognitive Level: Understanding

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: Assessment

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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4) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the clients temperature?

1. Every hour

2. Every 2 hours

3. Every 4 hours

4. Every shift

Answer: 3

Explanation: 3. Maternal temperature is taken every 4 hours unless it is above 37.5C. If elevated, it is taken every hour.

Page Ref: 515

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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5) The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching has been effective?

1. When a client arrives in labor, a urine specimen is obtained by catheter to check for protein and ketones.

2. When a client arrives in labor, she will be positioned supine to facilitate a normal blood pressure.

3. When a client arrives in labor, her prenatal record is reviewed for indications of domestic abuse.

4. When a client arrives in labor, a vaginal exam is performed unless birth appears to be imminent.

Answer: 4

Explanation: 4. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal exam is performed after the vital signs are obtained.

Page Ref: 515

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: Evaluation

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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6) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Fetal heart rate of 130 with average variability

2. Blood pressure of 130/80

3. Maternal pulse of 160

4. Protein of +1 in urine

5. Odorless, clear fluid on underwear

Answer: 1, 2, 5

Explanation: 1. Fetal heart rate (FHR) of 110-160 with average variability is a normal indication.

2. Maternal vital sign of blood pressure below 140/90 is a normal indication.

5. Fluid clear and without odor if membranes ruptured is a normal indication.

Page Ref: 515

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn 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 professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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7) The client is being admitted to the birthing unit. As the nurse begins the assessment, the clients partner asks why the fetuss heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching?

1. The fetuss heart rate will vary between 110 and 160.

2. The heart rate is monitored to see whether the fetus is tolerating labor.

3. By listening to the heart, we can tell the gender of the fetus.

4. After listening to the heart rate, you will contact the midwife.

Answer: 3

Explanation: 3. Fetal heart rate is not a predictor of gender.

Page Ref: 515

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: Evaluation

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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8) The nurse has completed the physical assessment of a client in early labor, and proceeds with the social assessment. A social history of the client would include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Use of drugs and alcohol

2. Family violence or sexual assault

3. Current living situation

4. Type of insurance

5. Availability of resources

Answer: 1, 2, 3, 5

Explanation: 1. Risk factors such as the use of drugs or alcohol during the pregnancy can influence the labor and birth.

2. It is imperative to ask the woman about domestic violence and to assess any degree of psychologic or physical harm, either potential or real.

3. A social assessment includes asking about the womans current living situation. This dialog provides an opportunity for the nurse to continue to build support, to provide information when requested, and to be direct yet supportive.

5. A social assessment includes asking about resources available to the family.

Page Ref: 512

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: 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 professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Discuss the components of a social history and its function in caring for the laboring woman.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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9) A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of labor?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Fear/Anxiety related to discomfort of labor and unknown labor outcome

2. Knowledge, Deficient, related to lack of information about pushing methods

3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent

4. Pain, Acute, related to perineal trauma

5. Coping: Family, Compromised, related to labor process

Answer: 1, 3, 5

Explanation: 1. A Fear/Anxiety diagnosis would apply to the first stage of labor for a first-time labor client.

3. Contractions become more regular in frequency and duration, increasing discomfort and pain.

5. The woman and her boyfriend are about to undergo one of the most meaningful and stressful events in life together. Physical and psychologic resources, coping mechanisms, and support systems will all be challenged.

Page Ref: 509

Cognitive Level: Applying

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

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: Context and Environment: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1 Identify nursing diagnoses specific to the first, second, third, and fourth stages of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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10) The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first?

1. The sterile vaginal exam

2. Welcoming the couple

3. Auscultation of the fetal heart rate

4. Checking for ruptured membranes

Answer: 2

Explanation: 2. It is important to establish rapport and to create an environment in which the family feels free to ask questions. The support and encouragement of the nurse in maintaining a caring environment begin with the initial admission.

Page Ref: 509

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn 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: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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11) An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to do which of the following?

1. Insist that he leave the room for at least the next hour.

2. Tell him he is not being as effective as he was, and that he needs to let someone else take over.

3. Offer to remain with his partner while he takes a break.

4. Suggest that the clients mother might be of more help.

Answer: 3

Explanation: 3. Support persons frequently are reluctant to leave the laboring woman to take care of their own needs. The laboring woman often fears being alone during labor. Even though there is a support person available, the womans anxiety may be decreased when the nurse remains with her while he takes a break.

Page Ref: 539

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Support Systems

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: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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12) By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following?

1. Recognizing the client as an active participant in her own care.

2. Attempting to correct any misinformation the client might have received.

3. Acting as an advocate for the client.

4. Establishing rapport with the client.

Answer: 1

Explanation: 1. Understanding the couples expectations and plans helps the nurse provide optimal nursing care and facilitate the best possible birth experience.

Page Ref: 513

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: 4 Summarize the importance of incorporating family expectations and cultural beliefs into the nursing care plan.

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

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13) The labor and birth nurse is admitting a client. The nurses assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The clients partner asks the nurse the reason for these questions. What would the nurses best response be?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. These questions are asked of all women. Its no big deal.

2. Id prefer that your partner ask me all the questions, not you.

3. A clients preferences for her birth are important for me to understand.

4. Many women have beliefs about childbearing that affect these choices.

5. Im gathering information that the nurses will use after the birth.

Answer: 3, 4

Explanation: 3. The nurse incorporates the familys expectations into the plan of care to be culturally appropriate and to facilitate the birth.

4. The nurse incorporates the familys expectations into the plan of care to be culturally appropriate and to facilitate the birth.

Page Ref: 513

Cognitive Level: Analyzing

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 Summarize the importance of incorporating family expectations and cultural beliefs into the nursing care plan.

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

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14) The laboring client presses the call light and reports that her water has just broken. What would the nurses first action be?

1. Check fetal heart tones.

2. Encourage the mother to go for a walk.

3. Change bed linens.

4. Call the physician.

Answer: 1

Explanation: 1. When the membranes rupture, the nurse notes the color and odor of the amniotic fluid and the time of rupture and immediately auscultates the FHR.

Page Ref: 516

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn 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: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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15) The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority?

1. Encourage the husband to remain in the room.

2. Keep the client on bed rest at this time.

3. Apply an internal fetal scalp electrode.

4. Obtain a clean-catch urine specimen.

Answer: 2

Explanation: 2. Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse.

Page Ref: 518

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn 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: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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16) The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client?

1. Encourage the client to vocalize during contractions.

2. Perform vaginal exams only between contractions.

3. Provide a CD of soft music with sounds of nature.

4. Offer to teach the partner how to massage tense muscles.

Answer: 4

Explanation: 4. Massage is helpful for many clients, especially during latent and active labor. Massage can increase relaxation and therefore decrease tension and pain.

Page Ref: 519

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 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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17) The nurse is aware of the different breathing techniques that are used during labor. Why are breathing techniques used during labor?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. They are a form of anesthesia.

2. They are a source of relaxation.

3. They increase the ability to cope with contractions.

4. They are a source of distraction.

5. They increase a womans pain threshold.

Answer: 2, 3, 4, 5

Explanation: 2. When used correctly, breathing techniques can encourage relaxation.

3. When used correctly, breathing techniques can enhance the ability to cope with uterine contractions.

4. When used correctly, breathing techniques provide some distraction from the pain.

5. When used correctly, breathing techniques increase a womans pain threshold.

Page Ref: 520

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. C. 8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering. | 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: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

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

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18) Two hours after delivery, a clients fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take?

1. Massage the fundus until firm

2. Express retained clots

3. Increase the intravenous solution

4. Call the physician

Answer: 1

Explanation: 1. When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm.

Page Ref: 534

Cognitive Level: Applying

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

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

MNL LO: 3.2.4 Apply appropriate nursing care required during the immediate postpartum period.

19) Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently?

1. A full bladder impedes oxygen flow to the fetus.

2. Frequent voiding prevents bruising of the bladder.

3. Frequent voiding encourages sphincter control.

4. A full bladder can impede fetal descent.

Answer: 4

Explanation: 4. The woman should be encouraged to void because a full bladder can interfere with fetal descent. If the woman is unable to void, catheterization may be necessary.

Page Ref: 516

Cognitive Level: Applying

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

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: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

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

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20) The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following?

1. Hyperventilation

2. Seizure auras

3. Imminent birth

4. Anxiety

Answer: 1

Explanation: 1. These symptoms all are consistent with hyperventilation.

Page Ref: 520

Cognitive Level: Analyzing

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: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

21) A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful?

1. Talk to the client the entire time.

2. Turn on the television to distract the client.

3. Stand next to the bed with hands on the railing next to the client.

4. Sit silently in the room away from the bed.

Answer: 3

Explanation: 3. Standing next to the bed is supportive without being irritating. The laboring woman fears being alone during labor. The womans anxiety may be decreased when the nurse remains with her.

Page Ref: 539

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: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

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MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

22) A full-term infant has just been born. Which interventions should the nurse perform first?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Placing the infant in a radiant-heated unit

2. Suctioning the infant with a bulb syringe

3. Wrapping the infant in a blanket

4. Evaluating the newborn using the Apgar system

5. Offering a feeding of 5% glucose water

Answer: 1, 2, 4

Explanation: 1. If the newborn is placed in a radiant-heated unit, he or she is dried, laid on a dry blanket, and left uncovered under the radiant heat.

2. Newborns are suctioned with a bulb syringe to clear mucus from the newborns mouth.

4. The purpose of the Apgar score is to evaluate the physical condition of the newborn at birth.

Page Ref: 529

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn 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: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.

23) The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done?

1. To contract the uterus and minimize bleeding

2. To decrease breast milk production

3. To decrease maternal blood pressure

4. To increase maternal blood pressure

Answer: 1

Explanation: 1. Oxytocin is given to contract the uterus and minimize bleeding.

Page Ref: 533

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety, and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients

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and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

MNL LO: 3.2.4 Apply appropriate nursing care required during the immediate postpartum period.

24) A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention?

1. A soaked perineal pad since the last 15-minute check

2. An edematous perineum

3. The client experiencing tremors

4. A fundus located at the umbilicus

Answer: 1

Explanation: 1. If the perineal pad becomes soaked in a 15-minute period or if blood pools under the buttocks, continuous observation is necessary. As long as the woman remains in bed during the first hour, bleeding should not exceed saturation of one pad.

Page Ref: 534

Cognitive Level: Analyzing

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

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

MNL LO: 3.2.4 Apply appropriate nursing care required during the immediate postpartum period.

25) The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infants Apgar score?

1. 7

2. 8

3. 9

4. 10

Answer: 2

Explanation: 2. The strong cry earns 2 points. The crying with foot sole stimulation earns 2 points. The limb flexion and resistance earn 2 points each. Bluish color earns 0 points. The Apgar score is 8.

Page Ref: 529, 530

Cognitive Level: Applying

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

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ompetencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.

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26) Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply?

1. Im checking the blood vessels in the cord to see whether it has one artery and one vein.

2. Im checking the blood vessels in the cord to see whether it has two arteries and one vein.

3. Im checking the blood vessels in the cord to see whether it has two veins and one artery.

4. Im checking the blood vessels in the cord to see whether it has two arteries and two veins.

Answer: 2

Explanation: 2. Two arteries and one vein are present in a normal umbilical cord.

Page Ref: 530

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: 6 Describe nursing interventions for promoting the womans comfort during each stage of labor.

MNL LO: 3.2.4 Apply appropriate nursing care required during the immediate postpartum period.

27) At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infants Apgar score?

1. 7

2. 8

3. 9

4. 10

Answer: 3

Explanation: 3. Two points each are scored in each of the categories of heart rate, respiratory effort, muscle tone, and reflex irritability. One point is scored in the category of skin color. The total Apgar would be 9.

Page Ref: 529, 530

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn 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. 8. 8.Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.

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28) Upon delivery of the newborn, what nursing intervention most promotes parental attachment?

1. Placing the newborn under the radiant warmer.

2. Placing the newborn on the mothers abdomen.

3. Allowing the mother a chance to rest immediately after delivery.

4. Taking the newborn to the nursery for the initial assessment.

Answer: 2

Explanation: 2. As the baby is placed on the mothers abdomen or chest, she frequently reaches out to touch and stroke her baby. When the newborn is placed in this position, the father or partner also has a very clear, close view and can also reach out to touch the baby.

Page Ref: 531

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | 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: 7 Summarize immediate nursing care of the newborn following birth.

MNL LO: 3.2.4 Apply appropriate nursing care required during the immediate postpartum period.

29) A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action?

1. Determine who might be the father of the baby for paternity testing.

2. Ask the client what kind of birthing experience she would like to have.

3. Assess blood pressure and check for proteinuria.

4. Obtain a Social Services referral to discuss adoption.

Answer: 3

Explanation: 3. Preeclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority.

Page Ref: 512, 536

Cognitive Level: Applying

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

Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | 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: 10 Explore the nurses role in providing sensitive, developmentally responsive care to adolescent parents.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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30) As compared with admission considerations for an adult woman in labor, the nurses priority for an adolescent in labor would be which of the following?

1. Cultural background

2. Plans for keeping the infant

3. Support persons

4. Developmental level

Answer: 4

Explanation: 4. Because her cognitive development is incomplete, the younger adolescent may have fewer problem-solving capabilities. The very young woman needs someone to rely on at all times during labor. She may be more childlike and dependent than older teens.

Page Ref: 536

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | 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: 10 Explore the nurses role in providing sensitive, developmentally responsive care to adolescent parents.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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Copyright 2016 Pearson Education, Inc.

31) When caring for a 13-year-old client in labor, how would the nurse provide sensitive care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Using simple and concrete instructions

2. Providing soothing encouragement and comfort measures

3. Making all decisions for the client when she expresses a feeling of helplessness

4. Deciding whom the client should allow in the room

5. Providing encouragement and support of the clients decisions

Answer: 1, 2, 5

Explanation: 1. A client at this developmental stage will need concrete and simplified instructions.

2. Touch, soothing encouragement, and measures to promote her comfort help her maintain control and meet her needs for dependence.

5. Establishing rapport without recrimination will provide emotional support and encouragement.

Page Ref: 536

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment

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: 10 Explore the nurses role in providing sensitive, developmentally responsive care to adolescent parents.

MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family during the 1st stage of labor.

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Copyright 2016 Pearson Education, Inc.

32) An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Skin color: Body blue with pinkish extremities

2. Umbilical cord: two veins and one artery

3. Respiration rate of 30-60 irregular

4. Temperature of above 36.5C (97.8F)

5. Sole creases that involve the heel

Answer: 3, 4, 5

Explanation: 3. Normal findings would include a respiration rate of 30-60 irregular.

4. Normal findings would include temperature of above 36.5C (97.8F).

5. Normal findings would include sole creases that involve the heel.

Page Ref: 530

Cognitive Level: Understanding

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

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.

33) A clients labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do?

1. Go to the nurses station and immediately call the physician.

2. Run to the delivery room for an emergency birth pack.

3. Stay with the client and ask auxiliary personnel for assistance.

4. Hold back the infants head forcibly until the physician arrives for the delivery.

Answer: 3

Explanation: 3. If birth is imminent, the nurse must not leave the client alone.

Page Ref: 537

Cognitive Level: Analyzing

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

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 20. Understand ones role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks they pose to self and patients. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Delineate management of a nurse-managed precipitous labor and birth.

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

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