Chapter 6: Nursing Care During Labor and Birth My Nursing Test Banks

Chapter 6: Nursing Care During Labor and Birth

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. The nurse measures the frequency of a laboring womans contractions by noting:

a.

How long the patient states the contractions last

b.

The time between the end of one contraction and the beginning of the next

c.

The time between the beginning and the end of one contraction

d.

The time between the beginning of one contraction and the beginning of the next

ANS: D

The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.

DIF: Cognitive Level: Comprehension REF: Text Reference: 120

OBJ: Objective: 3 TOP: Topic: Components of the Birth Process

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The relaxation phase between contractions is important because:

a.

The laboring woman needs to rest

b.

The uterine muscles fatigue without relaxation

c.

The contractions can interfere with fetal oxygenation

d.

The infant progresses toward delivery at these times

ANS: C

Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

DIF: Cognitive Level: Comprehension REF: Text Reference: 122

OBJ: Objective: 3 TOP: Topic: Components of the Birth Process

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse recognizes the contraction duration and interval that could result in fetal compromise is:

a.

Duration shorter than 30 seconds, interval longer than 75 seconds

b.

Duration shorter than 90 seconds, interval longer than 120 seconds

c.

Duration longer than 90 seconds, interval shorter than 60 seconds

d.

Duration longer than 60 seconds, interval shorter than 90 seconds

ANS: C

Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

DIF: Cognitive Level: Analysis REF: Text Reference: 121-122

OBJ: Objective: 3 TOP: Topic: Components of the Birth Process

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

4. Vaginal examination reveals the presenting part is the infants head, which is well flexed on his/her chest. This presentation is referred to as:

a.

Vertex

b.

Military

c.

Brow

d.

Face

ANS: A

In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

DIF: Cognitive Level: Application REF: Text Reference: 123

OBJ: Objective: 3 TOP: Topic: Components of the Birth Process

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates:

a.

Fetal distress

b.

Fetal maturity

c.

Intact gastrointestinal tract

d.

Dehydration in the mother

ANS: A

Green-stained amniotic fluid means that the fetus passed the first stool before birth and is an indicator of fetal compromise.

DIF: Cognitive Level: Analysis REF: Text Reference: 141

OBJ: Objective: 7 TOP: Topic: Monitoring the Fetus

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetuss hips are flexed and the knees are extended. The nurse would record this presentation as:

a.

Complete breech

b.

Frank breech

c.

Double footling

d.

Buttocks presentation

ANS: B

When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.

DIF: Cognitive Level: Application REF: Text Reference: 124, Figure 6-7

OBJ: Objective: 2, 3 TOP: Topic: Components of the Birth Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by:

a.

Contractions that are relieved by walking

b.

Discomfort in the abdomen and groin

c.

A decrease in vaginal discharge

d.

Regular contractions becoming more frequent and intense

ANS: D

In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

DIF: Cognitive Level: Application REF: Text Reference: 128

OBJ: Objective: 5 TOP: Topic: Normal Childbirth

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. The nurses most informative response would be that the woman should come when she:

a.

Feels increased fetal movement

b.

Has contractions that are 10 minutes apart

c.

Thinks her membranes have ruptured

d.

Has abdominal or groin discomfort

ANS: C

Ruptured membranes are an indication that the woman should go to the hospital or birthing center.

DIF: Cognitive Level: Application REF: Text Reference: 128

OBJ: Objective: 4, 5

TOP: Topic: Admission to the Hospital or Birth Center

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse, while caring for a woman in the first stage of labor, reminds the patient that contractions during this stage of labor:

a.

Get the baby positioned for delivery

b.

Push the baby into the vagina

c.

Dilate and efface the cervix

d.

Get the mother prepared for true labor

ANS: C

The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

DIF: Cognitive Level: Comprehension REF: Text Reference: 140, Table 6-3

OBJ: Objective: 4 TOP: Topic: The Labor Process

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. A woman is 7 cm dilated and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, the nurse assesses the most likely explanation for the womans change in behavior is that:

a.

Labor has progressed to the transition phase

b.

She lacked adequate preparation for the labor experience

c.

The woman would benefit from a different form of analgesia

d.

The contractions have increased from mild to moderate intensity

ANS: A

If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

DIF: Cognitive Level: Analysis REF: Text Reference: 140, Table 6-3

OBJ: Objective: 4 TOP: Topic: The Labor Process

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse explains that the function of contractions during the second stage of labor is to:

a.

Align the baby into the proper position for delivery

b.

Dilate and efface the cervix

c.

Push the baby out of the mothers body

d.

Separate the placenta from the uterine wall

ANS: C

The contractions push the baby out of the mothers body as the second stage of labor ends with the birth of the baby.

DIF: Cognitive Level: Knowledge REF: Text Reference: 141, Table 6-3

OBJ: Objective: 4 TOP: Topic: The Labor Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. The nurse explains that the third stage of labor ends with:

a.

Full cervical dilation

b.

Expulsion of the placenta and membranes

c.

Birth of the baby

d.

Engagement of the head

ANS: B

The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.

DIF: Cognitive Level: Knowledge REF: Text Reference: 141, Table 6-3

OBJ: Objective: 4 TOP: Topic: The Labor Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may:

a.

Interfere with cervical dilation

b.

Obstruct progress of the infant through the birth canal

c.

Obstruct the passage of the placenta

d.

Predispose the mother to uterine hemorrhage

ANS: D

A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.

DIF: Cognitive Level: Application REF: Text Reference: 148

OBJ: Objective: 8

TOP: Topic: Nursing Care Immediately After Birth

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

14. When the nurse observes the patient bearing down with contractions and crying out, The baby is coming! the nurse should:

a.

Go and find the physician

b.

Stay with the woman and use the call bell to get help

c.

Send the womans partner to locate a registered nurse

d.

Assist with deep breathing to slow the labor process

ANS: B

If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

DIF: Cognitive Level: Application REF: Text Reference: 142

OBJ: Objective: 7 TOP: Topic: The Labor Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of:

a.

A well-oxygenated fetus

b.

Compression of the umbilical cord

c.

Compression of the fetal head

d.

Uteroplacental insufficiency

ANS: A

Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

DIF: Cognitive Level: Analysis REF: Text Reference: 135

OBJ: Objective: 7 TOP: Topic: Monitoring the Fetus

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The nurse would coach the laboring woman with a fully dilated cervix to push by saying:

a.

At the beginning of a contraction, hold your breath and push for 10 seconds.

b.

Take a deep breath and push between contractions.

c.

Begin pushing when a contraction starts and continue for the duration of the contraction.

d.

At the beginning of a contraction, take two deep breaths and push with the second exhalation.

ANS: D

When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, then take another deep breath and push while exhaling.

DIF: Cognitive Level: Application REF: Text Reference: 138

OBJ: Objective: 7 TOP: Topic: The Labor Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The most important nursing activity during the fourth stage of labor is to:

a.

Monitor the frequency and intensity of contractions

b.

Provide comfort measures

c.

Assess for hemorrhage

d.

Promote bonding

ANS: C

Immediately after giving birth, every woman is assessed for signs of hemorrhage.

DIF: Cognitive Level: Comprehension REF: Text Reference: 148

OBJ: Objective: 8

TOP: Topic: Nursing Care Immediately After Birth

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. The nurse should:

a.

Check the fundus for position and firmness

b.

Report to the doctor immediately

c.

Change the pads and chart the time

d.

Time how long it takes to soak one pad

ANS: A

Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

DIF: Cognitive Level: Application REF: Text Reference: 148

OBJ: Objective: 8

TOP: Topic: Nursing Care Immediately After Birth

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurses initial action is:

a.

Stop the Pitocin infusion

b.

Increase the intravenous flow rate

c.

Reposition the woman to her side

d.

Start oxygen via nasal cannula

ANS: C

Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

DIF: Cognitive Level: Analysis REF: Text Reference: 140

OBJ: Objective: 7 TOP: Topic: Monitoring the Woman/Fetus

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. To relieve perineal bruising and edema following delivery the nurse should:

a.

Place an ice pack on the area for 12 hours

b.

Place a warm pack on the perineal area for 24 hours

c.

Administer aspirin to relieve inflammation

d.

Change the perineal pad frequently

ANS: A

An ice pack can be placed on the mothers perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours following delivery.

DIF: Cognitive Level: Comprehension REF: Text Reference: 148

OBJ: Objective: 8

TOP: Topic: Nursing Care Immediately After Birth

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. At 1 and 5 minutes of life, a newborns Apgar score is 9. The nurse understands that a score of 9 indicates this newborn:

a.

Will require resuscitation

b.

May have physical disabilities

c.

Will have above average intelligence

d.

Is in stable condition

ANS: D

Apgar scoring is a system for evaluating the infants need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2 with the highest score being 10. A score of 9 indicates that the newborn is stable.

DIF: Cognitive Level: Implementation REF: Text Reference: 143, Table 6-4

OBJ: Objective: 10 TOP: Topic: Care of the Infant After Birth

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. The husband of a woman in labor asks, What does it mean when the baby is at -1 station? After giving an explanation, the nurse determines that teaching was effective when the husband states the fetal head is:

a.

Above the ischial spines

b.

Below the ischial spines

c.

Engaged in the mothers pelvis

d.

Visible at the perineum

ANS: A

Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines. Minus stations are above the ischial spines.

DIF: Cognitive Level: Application REF: Text Reference: 128,Figure 6-10

OBJ: Objective: 4 TOP: Topic: Mechanisms of Labor

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is:

a.

Pain related to increasing frequency and intensity of contractions

b.

Fear related to the probable need for cesarean delivery

c.

Dysuria related to prolonged labor and decreased intake

d.

Risk for injury related to hemorrhage

ANS: D

In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.

DIF: Cognitive Level: Application REF: Text Reference: 148

OBJ: Objective: 8

TOP: Topic: Nursing Care Immediately After Birth

KEY: Nursing Process Step: Nursing Diagnosis

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

MULTIPLE RESPONSE

1. While caring for an Arab woman in labor, the nurse will be culturally sensitive and will:

Select all that apply.

a.

Provide for extreme modesty

b.

Assign a male caregiver

c.

Arrange for the husband/partner to participate in labor

d.

Provide adequate pain control

e.

Respect protective amulets

ANS: A, D, E

Arab women are extremely modest, usually have a low pain tolerance and wear various protective and religious amulets. The husband is in attendance, but not as a participant. Arabs prefer female care givers. If a male is in attendance, then the husband will remain in the room as long as the male is there.

DIF: Cognitive Level: Analysis REF: Text Reference: 116, Table 6-1

OBJ: Objective: 9 TOP: Topic: Cultural Considerations

KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

COMPLETION

1. After the pregnant woman is admitted to the labor suite, the nurse assesses the position of the baby as ROA; this means that the babys head is ______ ___________ _____________.

ANS: right occiput anterior

DIF: Cognitive Level: Application REF: Text Reference: 125, 126

OBJ: Objective: 8 TOP: Topic: Fetal Position

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: Right occiput anterior means that the babys right occiput is toward the anterior aspect of the mothers body.

2. The nurse explains that the four Ps of the birth process are ____________________, ____________________, ____________________, and ____________________.

ANS: powers, passenger, passage, and psyche

DIF: Cognitive Level: Knowledge REF: Text Reference: 119-121

OBJ: Objective: 2 TOP: Topic: Four Ps of the Birth Process

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: The four interrelated components of the process of labor and birth, called the Four Ps are Powers, Passenger, Passage, and Psyche.

3. After the membranes have ruptured, the nurse should assess the FHR for ____________________ minute(s).

ANS: 1

DIF: Cognitive Level: Application REF: Text Reference: 126

OBJ: Objective: 8 TOP: Topic: Assessment After Membrane Rupture

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

NOT: Rationale: The FHR is checked for 1 full minute to ensure that the baby is not in distress from cord compression resultant from the lost buoyancy.

OTHER

1. Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor. Place the 7 mechanisms of labor in the appropriate order.

a. Extension

b. Engagement

c. Descent

d. Flexion

e. Expulsion

f. Internal rotation

g. External rotation

ANS:

C, B, D, F, A, G, E

The process by which a normal vaginal delivery is accomplished requires the infant to make the descent into the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled.

DIF: Cognitive Level: Application REF: Text Reference: 126-128

OBJ: Objective: 4 TOP: Topic: Mechanisms of Labor

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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