Chapter 8: Nursing Care of Women with Complications During Labor and Birth My Nursing Test Banks

Chapter 8: Nursing Care of Women with Complications During Labor and Birth

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

MULTIPLE CHOICE

1. Following an amniotomy, the nursing assessment that should be reported immediately is:

a.

Fetal heart rate is regular at 154 beats/min

b.

Amniotic fluid is clear with flecks of vernix

c.

Amniotic fluid is watery and pale green

d.

Maternal temperature is 37.8C

ANS: C

Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.

DIF: Cognitive Level: Analysis REF: Text Reference: 174

OBJ: Objective: 3

TOP: Topic: Obstetrical Procedures-Amniotomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurses initial action should be to:

a.

Stop the oxytocin infusion

b.

Continue the infusion and report the findings to the physician

c.

Turn her on her left side and reassess the contractions

d.

Administer oxygen by mask

ANS: A

Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

DIF: Cognitive Level: Analysis REF: Text Reference: 175-176

OBJ: Objective: 3

TOP: Topic: Obstetrical Procedures-Induction of Labor

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nursing care of a woman with a third-degree laceration immediately after delivery would include:

a.

Warm compresses to the perineum

b.

Cold pack to the perineum

c.

Warm sitz bath

d.

Elevation of hips to prevent edema

ANS: B

Ice is applied to the perineum to reduce bruising and edema.

DIF: Cognitive Level: Application REF: Text Reference: 178

OBJ: Objective: 3

TOP: Topic: Obstetrical Procedures-Lacerations

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. The nurse knows that this labor pattern is described as:

a.

Normal

b.

Hypotonic

c.

Hypertonic

d.

False

ANS: B

The woman with hypotonic labor dysfunction begins labor normally, but contractions diminish after the active phase.

DIF: Cognitive Level: Comprehension REF: Text Reference: 188

OBJ: Objective: 5 TOP: Topic: Abnormal Labor

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. When a hypotonic labor dysfunction occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will:

a.

Perform an amniotomy

b.

Initiate tocolytic drugs

c.

Order a sedative for the patient

d.

Plan to do an emergency cesarean section

ANS: A

Medical treatment for hypotonic labor dysfunction includes an amniotomy if the membranes are intact as the first remedy.

DIF: Cognitive Level: Comprehension REF: Text Reference: 186

OBJ: Objective: 5 TOP: Topic: Abnormal Labor

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The nurse would assess an infant delivered with the use of forceps for:

a.

Loss of hair from contact with forceps

b.

Sacral hematoma

c.

Facial asymmetry

d.

Shoulder dislocation

ANS: C

Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry.

DIF: Cognitive Level: Analysis REF: Text Reference: 179

OBJ: Objective: 3

TOP: Topic: Obstetrical Procedures-Forceps Delivery

KEY: Nursing Process Step: Assessment

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

7. The new mother is distressed and tearful about the elevated dome over her babys posterior fontanelle. The nurses best response is, This condition will resolve itself in a few days. It is caused by:

a.

Prolonged pressure against the partially dilated cervix.

b.

Small leak of fluid through the posterior fontanel.

c.

Pressure of the forceps during delivery.

d.

The effect of the vacuum extractor.

ANS: D

The chignon is due to the effect of the vacuum extractor and will disappear in a few days.

DIF: Cognitive Level: Comprehension REF: Text Reference: 179

OBJ: Objective: 2 TOP: Topic: Chignon

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The frustrated patient in hypotonic labor complains My doctor wont induce my labor because of some silly Bishop score. He said I was a 4. What kind of magic number do I need? The nurse explains that prior to induction the patient should be a Bishop score of at least:

a.

6

b.

8

c.

10

d.

12

ANS: A

The Bishop Score evaluated the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the ACOG.

DIF: Cognitive Level: Comprehension REF: Text Reference: 175

OBJ: Objective: 2

TOP: Topic: Bishop Scoring for Vaginal Delivery

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

9. A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). To encourage fetal rotation and pain relief the nurse would position the patient:

a.

Prone with legs supported and give her a back massage

b.

Supine with legs bent at the knee

c.

Standing with support

d.

Sitting up and leaning forward on the over-bed table

ANS: D

A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.

DIF: Cognitive Level: Comprehension REF: Text Reference: 189

OBJ: Objective: 6 TOP: Topic: Abnormal Labor

KEY: Nursing Process Step: N/A

MSC: NCLEX: Health Promotion and Maintenance

10. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman asks the nurse, Please give me something. The most appropriate pain relief intervention for a woman in precipitate labor is to:

a.

Get an order for an intravenous narcotic

b.

Notify the anesthesiologist for an epidural block

c.

Stay and breathe with her during contractions

d.

Tell her to bear with it because she is close to delivery

ANS: C

The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.

DIF: Cognitive Level: Application REF: Text Reference: 192

OBJ: Objective: 6 TOP: Topic: Abnormal Labor

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

11. A woman who is 33 weeks pregnant is admitted to the obstetrical unit because her membranes ruptured spontaneously. She must be closely observed for signs of:

a.

Chorioamnionitis

b.

Hemorrhage

c.

Hypotension

d.

Amniotic fluid embolism

ANS: A

Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.

DIF: Cognitive Level: Analysis REF: Text Reference: 192

OBJ: Objective: 5

TOP: Topic: Premature Rupture of Membranes

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

12. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect?

a.

Maternal tachycardia

b.

Maternal hypertension

c.

Fetal bradycardia

d.

Fetal hypokalemia

ANS: A

Maternal tachycardia is the common negative side effect of terbutaline which should be corrected with a dose of propranolol.

DIF: Cognitive Level: Analysis REF: Text Reference: 193

OBJ: Objective: 6 TOP: Topic: Preterm Labor

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

13. The statement that indicates a woman understands activity limitations for the management of preterm labor is:

a.

After my shower in the morning, I do the laundry and straighten up the house, then I rest.

b.

I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.

c.

I have a 2-year-old to care for, but I try to rest as much as I can.

d.

I get really bored at home, so I go to the shopping mall for just a little while.

ANS: B

Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

DIF: Cognitive Level: Application REF: Text Reference: 194

OBJ: Objective: 5 TOP: Topic: Preterm Labor

KEY: Nursing Process Step: Evaluation

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

14. A student nurse questions the instructor as to what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. The best response is that the fundus of a patient with a cesarean section is:

a.

Not assessed until the second postoperative day

b.

Gently assessed as usual

c.

Assessed only if large clots appear in lochia

d.

Only once every shift

ANS: B

Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.

DIF: Cognitive Level: Analysis REF: Text Reference: 194

OBJ: Objective: 6 TOP: Topic: Cesarean Post-Op Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. A pulsating structure is felt during a vaginal examination of a woman in labor. To prevent compression of a prolapsed cord, the nurse would position the woman:

a.

On her hands and knees

b.

On her left side with a pillow placed between her legs

c.

On her back with her head lower than the rest of her body

d.

Supine with her legs elevated and bent at the knee

ANS: C

The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.

DIF: Cognitive Level: Application REF: Text Reference: 194-195

OBJ: Objective: 6

TOP: Topic: Emergencies During Childbirth-Prolapsed Umbilical Cord

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

16. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. The most appropriate nursing diagnosis is:

a.

Anxiety related to the development of postpartum complications

b.

Ineffective individual coping related to unfamiliarity with procedures

c.

Risk for ineffective parenting related to emergency cesarean section

d.

Grieving related to loss of expected birth experience

ANS: D

Women who have cesarean birth usually need greater support than those having vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.

DIF: Cognitive Level: Application REF: Text Reference: 183

OBJ: Objective: 3 TOP: Topic: Cesarean Section

KEY: Nursing Process Step: Nursing Diagnosis

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

17. A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. The nurse planning discharge instructions would teach the woman to:

a.

Report any increase in fetal activity

b.

Notify her obstetrician for a temperature above 37.8C

c.

Massage her breasts to promote uterine relaxation

d.

Rest in a side-lying Trendelenburg position with hips elevated

ANS: B

For the woman with PROM who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8C.

DIF: Cognitive Level: Application REF: Text Reference: 192

OBJ: Objective: 6

TOP: Topic: Premature Rupture of Membranes

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk

18. A woman who is 24 weeks pregnant is placed on an IV infusion of magnesium sulfate. The nurse should inform the patient that she might experience the side effect of this drug which is:

a.

Nausea and vomiting

b.

Headache

c.

Warm flush

d.

Urinary frequency

ANS: C

Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

DIF: Cognitive Level: Knowledge REF: Text Reference: 193

OBJ: Objective: 6 TOP: Topic: Preterm Labor

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, anxious about the welfare of her baby, anxious about how quickly she will recoverin short, anxious about everything. The nurse is aware that anxiety can affect labor by:

a.

Decreasing a womans pain sensitivity

b.

Reducing blood flow to the uterus

c.

Increasing the ability to tolerate pain

d.

Enhancing maternal pushing through greater muscle tension

ANS: B

Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

DIF: Cognitive Level: Comprehension REF: Text Reference: 191

OBJ: Objective: 2

TOP: Topic: Factors That Influence Labor Pain

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

20. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae which seems to occur with every breath she takes. The nurse should:

a.

Give the pain remedy

b.

Notify the charge nurse immediately

c.

Turn patient to her back and flex her knees

d.

Suggest that the coach give her a back rub

ANS: B

Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be immediately reported.

DIF: Cognitive Level: Analysis REF: Text Reference: 196

OBJ: Objective: 3 TOP: Topic: Uterine Rupture

KEY: Nursing Process Step: Implementation

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

MULTIPLE RESPONSE

1. The nurse reviews for the childbirth preparation class the rationales for labor induction, which are:

Select all that apply.

a.

Placenta previa

b.

Prolapse of cord

c.

High station of fetus

d.

Maternal diabetes

e.

Placental insufficiency

ANS: D, E

Maternal diabetes and placental insufficiency are rationales for induction. Options a, b, and c are contraindications for labor induction.

DIF: Cognitive Level: Analysis REF: Text Reference: 174

OBJ: Objective: 2 TOP: Topic: Rationales for Labor Induction

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

2. After an amniotomy, the nurse is alert for signs of infection which would include:

Select all that apply.

a.

Oral temperature of 99.8F

b.

Increase in FHR to 172 beats/min

c.

Flecks of vernix in the amniotic fluid

d.

Low back pain

e.

Edematous labia

ANS: B

Increase in the FHR indicates fetal distress. All the other options are normal findings for late pregnancy.

DIF: Cognitive Level: Analysis REF: Text Reference: 174

OBJ: Objective: 2 TOP: Topic: Post Amniotomy Care

KEY: Nursing Process Step: Assessment

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

3. The client has been declared to be in hypotonic labor. Among the interventions a nurse could apply to help the labor progress are:

Select all that apply.

a.

Encouraging the client to sit upright

b.

Assisting client to ambulate

c.

Stimulating the nipples

d.

Offering emotional support

e.

Allowing client to vent frustration

ANS: A, B, C

Sitting upright, ambulating, and stimulation of the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient, but do not stimulate more effective labor.

DIF: Cognitive Level: Analysis REF: Text Reference: 187

OBJ: Objective: 2 TOP: Topic: Hypotonic Labor

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. Following an amniotomy, the umbilical cord becomes depressed. The nurse prepares the client for an installation of a bolus of warm sterile saline into the uterus, which is called ____________________.

ANS: amnioinfusion

DIF: Cognitive Level: Application REF: Text Reference: 173

OBJ: Objective: 3 TOP: Topic: Amnioinfusion

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

NOT: Rationale: A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord.

2. The nurse explains to a client that a minimum score of ____________________ on the Bishop scale is predictive of successful labor induction.

ANS: 6

DIF: Cognitive Level: Application REF: Text Reference: 175

OBJ: Objective: 3 TOP: Topic: Bishop Scoring System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

NOT: Rationale: Refer to the Bishop Scale, Table 8-1

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