Chapter 17:Nursing Care of the Family During Labour and Birth

Question 1

1. Which alerts a nurse that a patient is in true labour?
   a. Passing thick, pink mucus
   b. Rupture of membranes
   c. Regular, strong contractions with cervical dilation
   d. Lightening

Answer 1

ANS: C
Regular, strong contractions with the presence of cervical change indicate that the patient is experiencing true labour. Loss of the mucous plug (operculum) often occurs during the first stage of labour or before the onset of labour, but it is not the indicator of true labour. Spontaneous rupture of membranes often occurs during the first stage of labour, but it is not the indicator of true labour. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labour, but this is not the indicator of true labour.

Question 2

2. A nurse teaches a pregnant patient about the characteristics of true labour contractions. The nurse evaluates the patient’s understanding of the instructions when they state, “True labor contractions will
   a. subside when I walk around.”
   b. cause discomfort over the top of my uterus.”
   c. continue and get stronger even if I relax and take a shower.”
   d. remain irregular but become stronger.”

Answer 2

ANS: C
True labour contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically, true labour contractions are felt in the lower back, radiating to the lower portion of the abdomen. During pre-labour, contractions tend to be irregular and felt in the abdomen above the navel. Typically, during pre-labour, the contractions often stop with walking or a change of position.

Question 3

3. When a nulliparous patient telephones the hospital to report that they are in labour, a nurse initially should
   a. tell the patient to stay home until her membranes rupture.
   b. emphasize that food and fluid intake should stop.
   c. arrange for the patient to come to the hospital for labour evaluation.
   d. ask the patient to describe why they believe they are in labor.

Answer 3

ANS: D
Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin the assessment and gather data. The amniotic membranes may or may not spontaneously rupture during labour. The patient may be instructed to stay home until the uterine contractions become strong and regular. The nurse may want to discuss the appropriate oral intake for early labour such as light foods or clear liquids, depending on the preference of the patient or her primary health care provider. Before instructing the woman to come to the hospital, the nurse should initiate the assessment during the telephone interview

Question 4

4. A nurse would expect to see what characteristic of amniotic fluid?
   a. Deep yellow colour
   b. Pale, straw colour with small white particles
   c. Acidic result on a Nitrazine test
   d. Absence of ferning

Answer 4

ANS: B
Amniotic fluid normally is a pale, straw-coloured fluid that may contain white flecks of vernix. Yellow-stained fluid may indicate fetal hypoxia 36 hours before rupture of membranes, fetal hemolytic disease, or intrauterine infection. Amniotic fluid produces an alkaline result on a Nitrazine test. The presence of ferning is a positive indication of amniotic fluid.

Question 5

5. When planning care for a labouring patient whose membranes have ruptured, a nurse recognizes that the patient’s risk for which has increased?
   a. Intrauterine infection
   b. Hemorrhage
   c. Precipitous labour
   d. Supine hypotension

Answer 5

ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labour, it does not result in precipitous labour. ROM has no correlation with supine hypotension.

Question 6

6. A nurse recognizes that a patient is most likely in true labour when they state
   a. “I passed some thick, pink mucus when I urinated this morning.”
   b. “My bag of waters just broke.”
   c. “The contractions in my uterus are getting stronger and closer together.”
   d. “My baby dropped, and I have to urinate more frequently now.”

Answer 6

ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labour. Loss of the mucous plug (operculum) often occurs during the first stage of labour or before the onset of labour, but it is not the indicator of true labour. Spontaneous rupture of membranes often occurs during the first stage of labour, but it is not the indicator of true labour. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labour, but this is not the indicator of true labour.

Question 7

7. A multiparous patient whose cervix is dilated to 5 cm is considered to be in which phase of labour?
   a. Latent phase
   b. Active phase
   c. Second stage
   d. Third stage

Answer 7

ANS: B
The latent phase is from the beginning of true labour until 4 cm of cervical dilation. The active phase of labour is characterized by cervical dilation of 5 to 10 cm. The second stage of labour begins when the cervix is completely dilated until the birth of the baby. The third stage of labour is from the birth of the baby until the expulsion of the placenta. This patient is in the active phase of labour

Question 8

8. When assessing a patient in the first stage of labour, a nurse recognizes that which is the most conclusive sign that uterine contractions are effective?
   a. Dilation of the cervix
   b. Descent of the fetus
   c. Rupture of the amniotic membranes
   d. Increase in bloody show

Answer 8

ANS: A
The vaginal examination reveals whether the patient is in true labour. Cervical change, especially dilation, in the presence of adequate labour indicates that the patient is in true labour. Descent of the fetus, or engagement, may occur before labour. Rupture of membranes may occur with or without the presence of labour. Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labour.

Question 9

9. Which is correct for a nurse to do when performing vaginal examinations to assess a patient’s progress in labour?
   a. Perform an examination at least once every hour during the active phase of
   labour.
   b. Perform the examination with the patient in the supine position.
   c. Wear two clean gloves for each examination.
   d. Discuss the findings with the patient and their partner.

Answer 9

ANS: D
The nurse should discuss the findings of the vaginal examination with the patient and their partner and report them to the primary care provider. A vaginal examination should be performed only when indicated by the status of the patient and their fetus. The patient should be positioned to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a labouring patient.

Question 10

10. A multiparous patient has been in labour for 8 hours. Their membranes have just ruptured. What is the nurse’s initial response?
    a. Prepare the patient for imminent birth.
    b. Notify the patient’s primary health care provider.
    c. Document the characteristics of the fluid.
    d. Assess the fetal heart rate and pattern.

Answer 10

ANS: D
The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after rupture of membranes (ROM) to ascertain fetal well-being, and the findings should be documented. ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse’s priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM

Question 11

11. What would a nurse most likely expect from a nulliparous patient who has just begun the second stage of labour?
    a. The patient will experience a strong urge to bear down.
    b. The patient will show perineal bulging.
    c. The patient will feel tired yet relieved that the first stage is over.
    d. The patient will show an increase in bright red bloody show.

Answer 11

ANS: C
Common maternal behaviours during the passive phase of the second stage of labour include feeling a sense of accomplishment and optimism because the first stage is completed. During the passive phase of the second stage of labour, the urge to bear down often is absent or only slight during the acme of contractions. Perineal bulging occurs near the end of the second stage of labour, not at the beginning of the second stage. An increase in bright red bloody show occurs during the late active phase of the first stage of labour.

Question 12

12. Which finding indicates to a nurse that the second stage of labour, the descent phase, has begun?
    a. The amniotic membranes rupture.
    b. The cervix cannot be felt during a vaginal examination.
    c. The patient experiences a strong urge to bear down.
    d. The presenting part is below the ischial spines.

Answer 12

ANS: C
During the active phase of the second stage of labour, the patient may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labour. The second stage of labour begins with full cervical dilation. Many patients may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labour, as early as 5-cm dilation.

Question 13

13. When managing the care of a patient in the second stage of labour, a nurse uses various measures to enhance the progress of fetal descent. Which interventions would be appropriate at this time?
    a. Encourage the patient to try various upright positions, including squatting and
    standing.
    b. Help the patient to start pushing as soon as her cervix is fully dilated.
    c. Continue an epidural anaesthetic so that pain is reduced and the patient can relax.
    d. Coach the patient to use sustained, 10-second, closed-glottis bearing-down efforts
    with each contraction.

Answer 13

ANS: A
Upright position and squatting both may enhance the progress of fetal descent. Many factors dictate when a patient will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the health care provider may allow the patient to “labour down” (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if the patient is able. The epidural may mask the sensations and muscle control needed for the patient to push effectively. Closed-glottis breathing may trigger the Valsalva manoeuvre, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

Question 14

14. Through vaginal examination a nurse determines that a nulliparous patient is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3 1/2 to 4 minutes. How should the nurse document these findings?
    a. First stage, latent phase
    b. First stage, active phase
    c. Second stage, active phase
    d. Second stage, latent phase

Answer 14

ANS: B
The first stage, active phase of maternal progress is indicated in the assessment of this woman. During the latent phase of the first stage of labour, the expected maternal progress would be 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the active phase, expected maternal progress is 4 to 10 cm dilation. During the latent and active phases of the second stage of labour, the woman is completely dilated and experiences a restful period of “labouring down.”

Question 15

15. What is the priority nursing action in caring for the newborn immediately after birth?
    a. Keep the newborn’s airway clear.
    b. Foster parent–newborn attachment.
    c. Dry the newborn and wrap the infant in a blanket.
    d. Administer eye drops and vitamin K.

Answer 15

ANS: A
The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent–infant attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The nursing activities would be (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering the infant with a warmed blanket while skin-to-skin with the mother. Once the newborn has spent time skin-to-skin and breastfeeding has been initiated, the nurse assesses the newborn’s physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet.

Question 16

16. When assessing a multiparous patient who has just given birth to a 2500 g boy, a nurse notes that the patient’s fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. What do these findings indicate to the nurse?
    a. The placenta has separated.
    b. A cervical tear occurred during the birth.
    c. The patient is beginning to hemorrhage.
    d. Clots have formed in the upper uterine segment.

Answer 16

ANS: A
Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

Question 17

17. Why would a nurse expect to administer an oxytocic to a patient after expulsion of their placenta?
    a. Relieve pain.
    b. Stimulate uterine contraction.
    c. Prevent infection.
    d. Facilitate rest and relaxation.

Answer 17

ANS: B
Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labour. Oxytocics are not used to treat pain or prevent infection. They cause the uterus to contract, which reduces blood loss. Oxytocics do not facilitate rest and relaxation.

Question 18

18. After an emergency birth, a nurse encourages the patient to breastfeed their newborn. What is the primary purpose of this activity?
    a. It will facilitate maternal–newborn interaction.
    b. It will stimulate the uterus to contract.
    c. It will prevent neonatal hypoglycemia.
    d. It will initiate the lactation cycle.

Answer 18

ANS: B
Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal–newborn interaction, but it is not the primary reason a postpartum patient is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth.

Question 19

19. A pregnant patient is in the third trimester. They ask a nurse to explain how they can tell true labour from pre-labour. What should the nurse tell the patient about true labour contractions?
    a. They increase with activity, such as ambulation.
    b. They decrease with activity.
    c. They are always accompanied by the rupture of the bag of waters.
    d. They alternate between a regular and irregular pattern.

Answer 19

ANS: A
True labour contractions become more intense with walking. False labour contractions often stop with walking or position changes. Rupture of membranes may occur before or during labour. True labour contractions are regular.

Question 20

20. A patient who is 39 weeks pregnant expresses fear about their impending labour and how they will manage. What is the basis for a nurse’s response?
    a. Offer assurance that the patient will do fine with labour.
    b. Indicate that it is normal to be fearful and explore their feelings.
    c. Confirm that labour is scary to think about but the actual birth isn’t too bad.
    d. Provide information about an epidural and reassure the patient that they will not
    feel any pain with this method of pain management.

Answer 20

ANS: B
Basing the response on the approach that is it normal to be anxious about labour and exploring their feelings allows the patient to share their concerns with the nurse and is a therapeutic communication tool. Offering assurance that they will do fine negates the patient’s fears and is not therapeutic. Confirming that labour is scary to think about, but the actual experience isn’t that bad negates the patient’s fears and offers a false sense of security. It is not true that every patient may have an epidural. A number of criteria must be met for use of an epidural. Furthermore, many patients still experience the feeling of pressure with an epidural.

Question 21

21. The primary difference between the labor of a nullipara and that of a multipara is the
    a. amount of cervical dilation.
    b. total duration of labour.
    c. level of pain experienced.
    d. sequence of labour mechanisms.

Answer 21

ANS: B
Multiparas usually labour more quickly than nulliparas, thus making the total duration of their labour shorter. Cervical dilation is the same for all labours. The level of pain is individual to the labouring patient, not to the number of labours they have experienced. The sequence of labour mechanisms remains the same with all labours.

Question 22

22. Nurses can help their patients by keeping them informed about the distinctive stages of labour. What description of the phases of the first stage of labour is accurate?
    a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4
    hours
    b. Active: Moderate, regular contractions; 4- to 10-cm dilation; duration variable in
    time
    c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes
    d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration
    of 1 to 2 hours

Answer 22

ANS: B
The active phase is characterized by moderate, regular contractions; 4- to 10-cm dilation; and duration variable in time. The latent phase is characterized by mild-to-moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus, and a duration of 6 to 8 hours. No official “lull” phase exists in the first stage. The transition phase is no longer considered a phase in the first stage of labour.

Question 23

23. Which should a nurse be aware of with regard to the procedures and criteria for admitting a patient to the hospital labour unit?
    a. They are not considered to be in true labour (according to the OTAS criteria) until
    a qualified health care provider says they are.
    b. They can have only their partner or predesignated doula with them at assessment.
    c. Their weight gain is calculated to determine whether they are at greater risk for
    Caesarean birth.
    d. The nurse should listen politely to the patient’s previous birthing experiences but
    should keep in mind that each birth is a unique experience.

Answer 23

ANS: C
Her weight is to be calculated to determine whether she is at greater risk for a Caesarean birth. The risk is especially great for petite women or those who have gained 16 kg or more. The Obstetrical Triage Acuity Scale (OTAS) does not assess the stage of labour but rather the priority with which the patient needs to be assessed. A patient can have anyone they wish present for their support. The details of previous birthing experiences are important; not only the mechanics of labour and the outcome but also the patient’s perceptions could influence their present attitude.

Question 24

24. A nurse is aware that which cannot be identified by Leopold manoeuvres?
    a. Gender of the fetus
    b. Point of maximal intensity
    c. Fetal lie and attitude
    d. Degree of the presenting part’s descent into the pelvis

Answer 24

ANS: A
The gender of the fetus cannot be determined by Leopold manoeuvres. Leopold manoeuvres help identify the number of fetuses, the fetal lie and attitude, the point of maximal intensity, and the degree of descent of the presenting part into the pelvis.

Question 25

25. A nurse would NOT USE which term when documenting information about uterine contractions?
    a. Frequency
    b. Intensity
    c. Resting tone
    d. Appearance

Answer 25

ANS: D
The inappropriate term for documenting uterine contractions is appearance. Uterine contractions are described in terms of frequency, intensity, duration, and resting tone.

Question 26

26. What should a nurse know about the point of maximal intensity (PMI) of the fetal heart rate (FHR)?
    a. It is usually directly over the fetal abdomen.
    b. In a vertex position it is heard above the mother’s umbilicus.
    c. It is heard lower and closer to the midline as the fetus descends and rotates
    internally.
    d. In a breech position it is heard below the mother’s umbilicus.

Answer 26

ANS: C
Nurses should be prepared for the shift. The PMI of the FHR usually is directly over the fetal back. In a vertex position it is heard below the mother’s umbilicus. In a breech position it is heard above the mother’s umbilicus.

Question 27

27. A nurse is aware that which statement is true with regard to a patient’s intake and output during labour?
    a. The tradition of restricting the labouring patient to clear liquids and ice chips is
    being challenged because regional anaesthesia is used more often than general
    anaesthesia.
    b. Intravenous (IV) fluids usually are necessary to ensure that the labouring patient
    stays hydrated.
    c. Routine use of an enema empties the rectum and is very helpful in order to have a
    clean birth.
    d. When a nulliparous patient experiences the urge to defecate, it often means birth
    will follow quickly.

Answer 27

ANS: A
Women are awake with regional anaesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labour are unlikely to be beneficial and may be harmful. Routine use of an enema is at best ineffective and may be harmful. A multiparous woman may feel the urge to defecate and it may mean birth will follow quickly, but not for a first-timer.

Question 28

28. Which action would be best for a nurse to suggest to assist a patient if they are experiencing back labour pain?
    a. Lie on your back for a while with your knees bent.
    b. Do less walking around.
    c. Take some deep, cleansing breaths.
    d. Lean over a birth ball with your knees on the floor.

Answer 28

ANS: D
The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged.

Question 29

29. Which description of the phases of the second stage of labour is accurate?
    a. Passive phase: Feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes
    b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated,
    duration is 5 to 15 minutes
    c. Descent phase: Significant increase in contractions, Ferguson reflux activated,
    average duration varies
    d. Transitional phase: Woman “labouring down,” fetal station is 0, duration is 15
    minutes

Answer 29

ANS: C
The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The passive phase is the lull, or “labouring down,” period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labour has no active phase. The transition phase used to be the final phase in first stage of labour but is no longer used in practice.

Question 30

30. Which would alert a nurse that the second stage of labour has begun?
    a. The patient has a sudden episode of vomiting.
    b. The nurse is unable to feel the cervix during a vaginal examination.
    c. Bloody show increases.
    d. The patient involuntarily tries to bear down.

Answer 30

ANS: B
The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced. Vomiting, an increase in bloody show, and involuntary bearing down are only suggestions of the ending of the transition phase of the first stage of labour.

Question 31

31. Which is a means of controlling the birth of the fetal head with a vertex presentation?
    a. The Ritgen maneuver
    b. Fundal pressure
    c. The lithotomy position
    d. The De Lee apparatus

Answer 31

ANS: A
The Ritgen manoeuvre extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth. The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider. The De Lee apparatus is sometimes used to suction fluid from the infant’s mouth.

Question 32

32. A patient who is G3T2P0A0L0 arrives in the labour unit. The most important nursing assessments are
    a. contraction pattern, amount of discomfort, and pregnancy history.
    b. fetal heart rate, maternal vital signs, and the woman’s nearness to birth.
    c. identification of ruptured membranes, the woman’s gravida and para, and her
    support person.
    d. last food intake, when labor began, and cultural practices the couple desires.

Answer 32

ANS: B
All options describe relevant intrapartum nursing assessments; however, this focused assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. This includes: obstetrical history, support person, pregnancy history, pain assessment, last food intake, and cultural practices.

Question 33

33. What should a nurse be aware of with regard to the third stage of labour?
    a. The placenta eventually detaches itself from a flaccid uterus.
    b. An expectant or active approach to managing this stage of labour reduces the risk
    of complications.
    c. It is important that the dark, roughened maternal surface of the placenta appear
    before the shiny fetal surface.
    d. The major risk for patients during the third stage is a rapid heart rate.

Answer 33

ANS: B
Active management facilitates placental separation and expulsion, reducing the risk of postpartum hemorrhage caused by uterine atony. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labour is postpartum hemorrhage.

Question 34

34. For patients who have a history of sexual abuse, a nurse can implement a number of care measures to help them view the childbirth experience in a positive manner. Which intervention would be best for the nurse to use while providing care?
    a. Tell the patient to relax and that it won’t hurt much.
    b. Limit the number of procedures that invade their body.
    c. Reassure the patient that as the nurse you know what is best.
    d. Allow unlimited providers to help care for the patient.

Answer 34

ANS: B
The number of invasive procedures, such as vaginal examinations, internal monitoring, and intravenous therapy, should be limited as much as possible. The nurse should always avoid using words and phrases that may result in the patient’s recalling the phrases of her abuser (e.g., “Relax, this won’t hurt” or “Open your legs”). The woman’s sense of control should be maintained at all times. The nurse should explain procedures at the patient’s pace and wait for permission to proceed. Protecting the patient’s environment by providing privacy and limiting the number of staff who observe the patient will help to make her feel safe.

Question 35

35. When implementing labour and birth care, a nurse would anticipate that a woman from which ethnic group would likely not have the father of the baby in attendance?
    a. Laotian
    b. European
    c. Islamic d. Canadia

Answer 35

ANS: C
Islamic women are very modest (i.e., they need to keep hair and body covered) and may not accept the presence of a man during childbirth, not even the father. Among the Laotian (Hmong), the father plays an important role in the birth.

Question 36

36. A labouring woman is lying in the supine position. The best nursing action at this time is to
    a. ask her to turn to one side.
    b. elevate her feet and legs.
    c. take her blood pressure.
    d. determine whether fetal tachycardia is present.

Answer 36

ANS: A
The woman’s supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental blood flow. Elevating her legs will not relieve the pressure from the inferior vena cava. If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side. Blood pressure readings may be obtained when the patient is in the appropriate and safest position.

Question 37

37. Which nursing assessment indicates that a patient who is in second-stage labour is almost ready to give birth?
    a. The fetal head is felt at 0 station during vaginal examination.
    b. Bloody mucus discharge increases.
    c. The vulva bulges and encircles the fetal head.
    d. The membranes rupture during a contraction.

Answer 37

ANS: C
A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labour process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labour process and does not indicate an imminent birth.

Question 38

1. Which assessment findings would indicate that a labouring patient’s membranes are probably ruptured? (Select all that apply.)
   a. Nitrazine test paper is yellow.
   b. Nitrazine test paper is blue-green.
   c. Absence of ferning of vaginal fluid under a microscope.
   d. Nitrazine test paper is deep blue.
   e. Nitrazine test paper is olive-green.
   f. Appearance of ferning of vaginal fluid under a microscope.

Answer 38

ANS: B, D, F
Membranes are most likely ruptured when Nitrazine paper is blue-green, blue-grey, or deep blue and if ferning is observed under a microscope with a sample of fluid from the vagina. Membranes are probably intact if the Nitrazine paper is yellow, olive-yellow, or olive-green.

Question 39

The vaginal examination is an essential component of labour assessment. It reveals whether the patient is in true labour and enables the examiner to determine whether membranes have ruptured. This examination is often stressful and uncomfortable for the patient and should be performed only when indicated. Please match the correct step number, from 1 to 7, with each component of a vaginal examination of the labouring patient.
a. After obtaining permission, gently insert the index and middle fingers into the
vagina.
b. Explain findings to the patient.
c. Position the patient to prevent supine hypotension.
d. Use sterile gloves and soluble gel for lubrication.
e. Document findings and report to the provider.
f. Cleanse the perineum and vulva if necessary.
g. Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.
1. Step 1
2. Step 2
3. Step 3
4. Step 4
5. Step 5
6.step 6
7. step 7

Answer 39

1. ANS: D
2. ANS: C
3. ANS: F
4. ANS: A
5. ANS: G
6. ANS: B
7. ANS: E