Question 1

A patient in the transition phase of labor is 8 cm dilated and reports feeling the need to push.Which is the nurse's priority teaching for this patient?&#10;A) Warning her labor coach of potential irritability during this phase&#10;B) Assisting with pant-blow breathing&#10;C) Instructing her to inform the nurse of feelings of nausea&#10;D) Assisting her into a position to push effectively&#10;

Accepted Answer

During the transition phase of labor, when the patient feels the urge to push but is not fully dilated (10 cm), it is important to prevent premature pushing which can lead to cervical swelling and complications. Pant-blow breathing helps control the urge to push until full dilation is achieved.

Question 2

A father who is watching the nurse prepare an injection of vitamin K for his infant asks why the medication is necessary.Which is the nurse's best explanation?&#10;A) &#34;It is a routine procedure for all infants immediately after birth.&#34;&#10;B) &#34;It prevents eye infections and preserves eyesight.&#34;&#10;C) &#34;Newborns can't produce vitamin K and are at risk for bleeding.&#34;&#10;D) &#34;It is given to promote blood clotting till the newborn begins eating.&#34;&#10;

Accepted Answer

&#34;It is given to promote blood clotting till the newborn begins eating.&#34;

Question 3

The nurse is caring for a patient in labor with a known history of drug abuse.How does the patient's history impact the nursing plan of care?&#10;A) Narcotics should not be administered to someone with a history of drug abuse.&#10;B) Higher dosages of medications may be needed to manage this patient's pain.&#10;C) Local anesthetics are the anesthetic of choice for this patient.&#10;D) The woman should be encouraged to use nonpharmacological pain management.&#10;

Accepted Answer

Patients with a history of drug abuse may have developed a tolerance to certain medications, including narcotics, which may necessitate higher dosages to effectively manage pain.

Question 4

The physician performs an amniotomy on a laboring woman.Which is the nurse's priority of care after the procedure?&#10;A) Pain assessment&#10;B) Measuring fetal heart tones&#10;C) Assessing cervical dilation&#10;D) Encouraging intake of clear liquids&#10;

Accepted Answer

Measuring fetal heart tones is the priority after an amniotomy to ensure fetal well-being and detect any changes in fetal heart rate. Pain assessment, assessing cervical dilation, and encouraging intake of clear liquids are also important but not as high of a priority as monitoring the fetal heart rate.

Question 5

A laboring patient has received IV fentanyl for labor pain management and requests it again after the cervical check indicates she is 10 cm dilated and ready to start pushing.Which is the nurse's best response to the patient's request?

A) "Try to give one or two good pushes,and then I'll get your medication for you."
B) "Receiving medication now is a good idea to help you control the pain of delivery."
C) "Administering a narcotic now could be dangerous because it will suppress the baby's breathing."
D) "If I give you fentanyl now,you might miss the birth of your baby because you'll be asleep."

Accepted Answer

Administering narcotics like fentanyl too close to delivery can suppress the newborn's respiratory effort, posing a risk to the baby's ability to breathe effectively at birth.

Question 6

The nurse is caring for a patient who received an epidural analgesic minutes ago.Which assessment finding should the nurse report to the provider immediately?&#10;A) A slowdown in labor contractions&#10;B) A reduction in blood pressure&#10;C) Complaints of numbness in the legs&#10;D) Shortness of breath,itching,and hives&#10;

Accepted Answer

Shortness of breath, itching, and hives are signs of an allergic reaction to the epidural analgesic and require immediate intervention by the provider. A slowdown in labor contractions and complaints of numbness in the legs are expected side effects of an epidural. A reduction in blood pressure is also a possible side effect but may not require immediate intervention unless it becomes clinically significant.

Question 7

A woman in labor uses hypnosis to manage pain,which the nurse recognizes as a component of which method?&#10;A) Dick-Read method&#10;B) Bradley method&#10;C) Lamaze method&#10;D) Leboyer method&#10;

Accepted Answer

The Dick-Read method emphasizes the role of fear and tension in childbirth and teaches relaxation techniques, including hypnosis, to manage pain. The Bradley method focuses on natural childbirth without medications, Lamaze method includes breathing techniques and relaxation, and Leboyer method emphasizes providing a calm and gentle birth environment for the baby.

Question 8

A woman in the latent phase of labor is admitted with a diagnosis of group B Streptococcus.Which order should the nurse question?&#10;A) Begin an infusion of lactated Ringer's IV at 125 mL/hr&#10;B) Collect her complete blood cell (CBC)count,blood type,Rh,and urinalysis&#10;C) Prepare for an amniotomy&#10;D) Administer penicillin G 5 million units IV times one dose,then 2.5 million units every 4 hours&#10;

Accepted Answer

An amniotomy, or artificial rupture of membranes, is not recommended for a patient with group B Streptococcus as it increases the risk of infection for both the mother and the baby. The nurse should question this order and inform the healthcare provider of the patient's diagnosis. The other orders are appropriate for a patient in the latent phase of labor with group B Streptococcus. Infusing lactated Ringer's solution helps maintain hydration and prevent dehydration during labor. Collecting a CBC, blood type, Rh, and urinalysis is necessary for monitoring the patient's condition and providing appropriate interventions if necessary. Administering penicillin G is the standard treatment for group B Streptococcus to prevent neonatal infection.

Question 9

The nurse who is teaching a class for peers to explain the physiology of pain explains that somatic pain is caused by what?&#10;A) Decrease in blood supply to the uterus during contractions&#10;B) Stretching of the perineum during fetal descent&#10;C) Afferent and efferent impulses sent from fibers near the cervix&#10;D) The early stages of labor from stretching and dilation of the cervix&#10;

Accepted Answer

Somatic pain is typically associated with the skin, muscles, and soft tissues, such as the stretching of the perineum during fetal descent.

Question 10

A newborn has a 1-minute Apgar of 3 and a 5-minute Apgar of 5.When will the next Apgar be performed by the nurse?&#10;A) At 6 minutes of life&#10;B) Every 15 minutes until a score of 10 is achieved&#10;C) 4 minutes later&#10;D) At 10 minutes of life&#10;

Accepted Answer

The next Apgar score after a 5-minute score of less than 7 should be performed at 10 minutes of life. This is to continue monitoring the newborn's condition and response to resuscitation if needed.

Question 11

A woman in active labor has not progressed since reaching 6 cm dilation.Which is the nurse's priority of care?&#10;A) Assisting with bladder emptying&#10;B) Administering analgesics&#10;C) Encouraging and reinforcing relaxation and breathing&#10;D) Encouraging position changes&#10;

Accepted Answer

The answer of A woman in active labor has not...

Question 12

The nurse accepts a newborn from the provider immediately after delivery and assesses the 1-minute Apgar as 6.How does the nurse maintain thermoregulation for this newborn?&#10;A) Wrap the infant in warm blankets&#10;B) Apply a hat&#10;C) Place the infant skin-to-skin with the mother&#10;D) Place the infant on a radiant warmer&#10;

Accepted Answer

The answer of The nurse accepts a newborn from the...

Question 13

Which patient does the nurse consider at lowest risk for urinary retention?&#10;A) The patient who received an IV narcotic for pain management&#10;B) The patient who received a pudendal block prior to delivery&#10;C) The patient who received an epidural anesthetic&#10;D) The patient who received a spinal anesthetic&#10;

Accepted Answer

The answer of Which patient does the nurse consider at...

Question 14

Which nonpharmacological pain relief measures can the nurse provide a laboring woman to ease the pain of contractions? (Select all that apply.)&#10;A) Ice chips&#10;B) A cool washcloth to the forehead&#10;C) Progressive relaxation&#10;D) Breathing techniques&#10;E) Diversion and distraction&#10;

Accepted Answer

The answer of Which nonpharmacological pain relief measures can the...

Question 15

The nurse assesses a patient immediately after she receives an epidural anesthetic to control labor pain and notes tachycardia,hypertension,and reports of dizziness and a metallic taste in her mouth.Which is the nurse's priority intervention?

A) Administering diphenhydramine if ordered
B) Encouraging deep breathing and relaxation techniques
C) Notifying the provider immediately
D) Administering an IV fluid bolus if ordered

Accepted Answer

The answer of The nurse assesses a patient immediately after...

Question 16

After delivery of an infant and prior to delivery of the placenta,which is the priority assessment of the mother?&#10;A) Suturing of any tears&#10;B) Administering oxytocin infusion&#10;C) Examination of the umbilical cord&#10;D) Condition of the cervix,vagina,and perineum&#10;

Accepted Answer

The answer of After delivery of an infant and prior...

Question 17

During contractions,which is the nurse's priority teaching for a woman in active labor?&#10;A) Encouraging proper breathing and relaxation techniques&#10;B) Encouraging position changes&#10;C) Encouraging urination&#10;D) Teaching about the progression of labor contractions&#10;

Accepted Answer

The answer of During contractions,which is the nurse's priority teaching...

Question 18

A patient is in active labor,6 cm dilated,100% effaced with intact amniotic membranes.Which procedure does the nurse anticipate?&#10;A) Amniotomy&#10;B) Episiotomy&#10;C) Amnioinfusion&#10;D) Intermittent fetal monitoring&#10;

Accepted Answer

The answer of A patient is in active labor,6 cm...

Question 19

Which is the nurse's priority of care during the immediate postdelivery period?&#10;A) Inspection of the placenta&#10;B) Administration of naloxone&#10;C) Assessment of the umbilical cord&#10;D) Care of the newborn&#10;

Accepted Answer

The answer of Which is the nurse's priority of care...

Question 20

A multipara woman presents to the labor unit in active labor,dilated to 9 cm,and requesting something to manage the pain.Which anesthetic is most appropriate for this patient?&#10;A) Epidural&#10;B) Spinal&#10;C) IV narcotic&#10;D) Local&#10;

Accepted Answer

The answer of A multipara woman presents to the labor...

Deck 10: Nursing Care During Labor