Ch. 16

Question 1

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

Answer 1

The contractions in my uterus are getting stronger and closer together

Question 2

The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the womans understanding of the instructions when she states, True labor contractions will

Answer 2

Continue and get stronger even if I relax and take a shower.

Question 3

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

Answer 3

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

Question 4

What is an expected characteristic of amniotic fluid

Answer 4

Pale, straw color with small white particles

Question 5

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

Answer 5

Intrauterine infection

Question 6

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

Answer 6

Evaluate the intensity by pressing the fingertips into the uterine fundus

Question 7

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be

Answer 7

Dilation of the cervix

Question 8

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

Answer 8

Discuss the findings with the woman and her partner.

Question 9

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

Answer 9

Assess the fetal heart rate and pattern

Question 10

A nulliparous woman who has just begun the second stage of her labor would most likely

Answer 10

Feel tired yet relieved that the worst is over

Question 11

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

Answer 11

The woman experiences a strong urge to bear down

Question 12

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:

Answer 12

Encouraging the woman to try various upright positions, including squatting and standing

Question 13

Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as

Answer 13

First stage, active phase

Question 14

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

Answer 14

Keeping the newborns airway clear

Question 15

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the womans fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that

Answer 15

The placenta has separated

Question 16

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

Answer 16

Stimulate uterine contraction

Question 17

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to

Answer 17

Stimulate the uterus to contract

Question 18

A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that true labor contractions

Answer 18

Increase with activity such as ambulation

Question 19

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurses best response is

Answer 19

Its normal to be anxious about labor. Lets discuss what makes you afraid

Question 20

For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of

Answer 20

Formulation of the womans plan of care for labor.

Question 21

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

Answer 21

Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours

Question 22

It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care?

Answer 22

The patients weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth

Question 23

Leopold maneuvers would be an inappropriate method of assessment to determine

Answer 23

Gender of the fetus.

Question 24

In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except

Answer 24

Appearance (shape and height)

Question 25

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is

Answer 25

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

Question 26

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?

Answer 26

When accelerations of the fetal heart rate (FHR) are noted

Question 27

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

Answer 27

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

Question 28

If a woman complains of back labor pain, the nurse could best suggest that she

Answer 28

Lean over a birth ball with her knees on the floor

Question 29

Which description of the phases of the second stage of labor is accurate

Answer 29

Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied

Question 30

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

Answer 30

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

Question 31

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

Answer 31

The Ritgen maneuver

Question 32

Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)

Answer 32

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

Question 33

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

Answer 33

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

Question 34

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?

Answer 34

Limiting the number of procedures that invade her body

Question 35

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

Answer 35

Mexico

Question 36

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?

Answer 36

Active phase

Question 37

The primary difference between the labor of a nullipara and that of a multipara is the

Answer 37

Total duration of labor

Question 38

What is an essential part of nursing care for the laboring woman?

Answer 38

Helping the woman manage the pain

Question 39

A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are

Answer 39

Fetal heart rate, maternal vital signs, and the womans nearness to birth.

Question 40

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be:

Answer 40

Discharged home to await the onset of true labor.

Question 41

A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to

Answer 41

Ask her to turn to one side.

Question 42

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

Answer 42

The vulva bulges and encircles the fetal head

Question 43

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant?

Answer 43

9

Question 44

The nurse thoroughly dries the infant immediately after birth primarily to

Answer 44

Reduce heat loss from evaporation

Question 45

Women who have participated in childbirth education classes often bring a birth bag or Lamaze bag with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including

Answer 45

Rolling pin
Tennis balls.
Pillow
Stuffed animal or photo

Question 46

VE - Step 1

Answer 46

Use sterile gloves and soluble gel for lubrication

Question 47

VE - Step 2

Answer 47

Position the woman to prevent supine hypotension

Question 48

VE- Step 3

Answer 48

Cleanse the perineum and vulva if necessary.

Question 49

VE- Step 4

Answer 49

After obtaining permission, gently insert the index and middle fingers into the vagina

Question 50

VE- Step 5

Answer 50

Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid

Question 51

VE- Step 6

Answer 51

Explain findings to the patient

Question 52

VE - Step 7

Answer 52

Document findings and report to the provider

Question 53

Instruct the patient and partner in the use of specific relaxation techniques

Answer 53

Acute pain related to contractions

Question 54

Continue to provide comfort measures and minimize distractions

Answer 54

Risk for impaired individual coping

Question 55

Group care activities as much as possible

Answer 55

Fatigue related to energy expenditure during labor and birth

Question 56

Orient the patient and family to the labor and birth unit

Answer 56

Anxiety related to labor and the birthing process

Question 57

Encourage frequent voiding and catheterize if necessary

Answer 57

Risk for impaired urinary elimination