Nursing care of family during labor

Question 1

1. The nurse is talking with a woman who is 36 weeks gestation during prenatal visit. Which statement indicates that the
   woman understand the onset of labor?
   a. “I need to go to the hospital as soon as the contractions become painful”
   b. “If I experience bright red vaginal bleeding I know that I am about to deliver”
   c. “I need to go to the hospital when I am having regular contractions and bloody show”
   d. “My labor will not start until after my membranes rupture and I gush fluid

Answer 1

C. I need to go to the hospital when i am having regular contractions and bloody show.

Question 2

2. The Nurse is caring for a woman who is in labor. She is 8cm dilated. How will the nurse best support the woman
   during her labor?
   a. Leave her alone most of the rime
   b. Offer her a back rub during contractions
   c. Offer her sips of oral fluids
   d. Provide her with warm blankets

Answer 2

B. Offer her back rub during contractions

Question 3

3. After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes
   stated by the client would indicate to the nurse that the teaching was effective?
   a. Shortens the second stage of labor
   b. Enlarges the pelvic inlet
   c. Prevents perineal edema
   d. Ensures quick placenta delivery

Answer 3

A. Shortens the second stage of labor.

Question 4

4. The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, “The baby is coming!” which of the following would be the nurse’s first action?
   a. Inspect the perineum
   b. Time the contractions
   c. Auscultate the fetal heart rate
   d. Contact the birth attendant

Answer 4

A. Inspect the perineum

Question 5

5. A woman delivered a 7 lb boy spontaneous vaginal delivery 30 minutes ago. Her fundus is firm at the umbilicus and
   she has moderate lochia rubra. Which nursing diagnosis is highest priority as the nurse plan care?
   a. Risk for infection related to episiotomy
   b. Constipation related to fear of pain
   c. Potential for impaired urinary elimination related to perennial edema
   d. Deficient knowledge related to lack of knowledge regarding newborn care

Answer 5

C. Potential for impaired urinary elimination related to perineal edema

Question 6

6. A woman is admitted to the hospital in labor. Vaginal examination reveals that she is 8cm dilated. At this point in her labor, which of the following statements would the nurse expect her to make?
   a. “I can’t decide to what to name my baby.”
   b. “It feels good to push with each contraction.”
   c. “Take your hand off my stomach when I have contraction.”
   d. “This isn’t as bad as I expected.”

Answer 6

B.” It feels good to push with each contraction.”

Question 7

7. A woman who has been in labor for 6 hours is now 9 cm dilated and has intense contraction every 1 to 2 minutes. She
   is anxious and feels the need to bear down with her contractions. What is the best action for the nurse to take?
   a. Allow her to push so that delivery can be expedited
   b. Encourage panting breathing through contractions to prevent pushing
   c. Reposition her in a squatting position to make her more comfortable
   d. Provide back rubs during contractions to distract her.

Answer 7

B. Encourage panting breathing through contractions to prevent pushing.

Question 8

8. A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40
   weeks’ gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be
   the priority at this time?
   a. Placing the client in bed to begin fetal monitoring.
   b. Preparing for immediate delivery.
   c. Checking for ruptured membranes.
   d. Providing comfort measures.

Answer 8

B. Preparing for immediate delivery.

Question 9

9. What are the important considerations that the nurse must remember after the placenta is delivered?
10. Check if the placenta is complete including the membranes
11. Check if the cord is long enough for the baby
12. Check if the umbilical cord has 3 blood vessels
13. Check if the cord has a meaty and shiny portion
    a. 1 and 3
    b. 2 and 4
    c. 1, 3, and 4
    d. 2 and 3

Answer 9

a. 1 and 3
1. Check if the placenta is complete including the membranes
3. Check if the umbilical cord has 3 blood vessels.

Question 10

10. A woman is in fourth stage of labor. She and her new daughter are together in the room. What assessment are essentials for nurse to make during this time?
    a. Assess the pattern and frequency of contractions and the infant’s vital signs
    b. Assess the woman’s vital signs, fundus, bladder, perineal condition and lochia. Assess the infant’s vital signs
    c. Assess the woman’ vital signs , fundus, perineal condition and lochia. Return the infant to the nursery.
    d. Assess the infant for obvious abnormalities. Assess the woman for blood loss and firm uterine contraction

Answer 10

B. Assess the woman’s vital signs, fundus, bladder, perineal condition and lochia. Assess the infant’s vital signs