Question 1

The laboring client presses the call light and reports that her water has just broken.The nurse's first action would be to:&#10;A)Check fetal heart tones.&#10;B)Encourage the mother to go for a walk.&#10;C)Change bed linen.&#10;D)Call the physician.&#10;

Accepted Answer

Checking fetal heart tones assesses the well-being of the baby and is the priority when the client's water breaks. The nurse can then inform the physician of the situation. Changing the bed linen and encouraging the mother to go for a walk can be done after assessing fetal heart tones and informing the physician.

Question 2

After delivery of the newborn,the nursing intervention that most promotes parental attachment is:&#10;A)Placing the newborn under the radiant warmer.&#10;B)Placing the newborn on the maternal abdomen.&#10;C)Allowing the mother a chance to rest immediately after delivery.&#10;D)Taking the newborn to the nursery for the initial assessment.&#10;

Accepted Answer

Placing the newborn on the maternal abdomen, also known as skin-to-skin contact, immediately after delivery has been shown to promote parental attachment. This closeness allows the baby to smell and hear their mother's voice, which helps to promote bonding. Additionally, skin-to-skin contact can help regulate the baby's breathing, temperature, and heart rate. Therefore, option B is the best choice for promoting parental attachment.

Question 3

The client presents to Labor and Delivery stating that her water broke 2 hours ago.Barring any abnormalities,how often would the nurse expect to take the client's temperature?&#10;A)Every hour&#10;B)Every 2 hours&#10;C)Every 4 hours&#10;D)Every shift&#10;

Accepted Answer

After a client's water breaks, it is standard practice to monitor the client's temperature every 4 hours to check for signs of infection, unless there are specific concerns or policies that dictate more frequent monitoring.

Question 4

An expectant father has been at the bedside of his laboring partner for more than 12 hours.An appropriate nursing intervention would be to:&#10;A)Insist that he leave the room for at least the next hour.&#10;B)Tell him he is not being as effective as he was,and needs to let someone else take over.&#10;C)Offer to remain with his partner while he takes a break.&#10;D)Suggest that the client's mother might be of more help.&#10;

Accepted Answer

Offering the expectant father a break and offering to stay with his partner is an appropriate nursing intervention. This allows the father to rest and recharge while ensuring that his partner is not left alone during the labor process. Insisting that he leave or suggesting someone else take over may be perceived as insensitive and unhelpful. The choice of involving the client's mother should be left to the client's preference and may not be appropriate in every situation.

Question 5

The laboring client is complaining of tingling and numbness in her fingers and toes,dizziness,and spots before her eyes.The nurse recognizes that these are clinical manifestations of:&#10;A)Hyperventilation.&#10;B)Seizure auras.&#10;C)Imminent birth.&#10;D)Anxiety.&#10;

Accepted Answer

Tingling and numbness in the fingers and toes, dizziness, and spots before the eyes are all common symptoms of hyperventilation, which can occur during labor due to quick, shallow breathing. The nurse should encourage the client to slow down her breathing and take deeper, more controlled breaths to alleviate these symptoms. Seizure auras and imminent birth may have different symptoms, while anxiety can present with a variety of symptoms beyond those listed.

Question 6

Compared with admission considerations for an adult woman in labor,the nurse's priority for an adolescent in labor would be to assess:&#10;A)Cultural background.&#10;B)Plans for keeping the infant.&#10;C)Support persons.&#10;D)Developmental level.&#10;

Accepted Answer

The nurse's priority for an adolescent in labor would be to assess their developmental level. Adolescents are still going through physical, cognitive, and emotional changes, and it is important for the nurse to understand their level of development in order to provide appropriate care and support. This can affect the way the nurse communicates with the adolescent and the type of guidance they may need during labor and delivery. Cultural background, plans for keeping the infant, and support persons are also important considerations, but are of secondary priority compared to assessing the adolescent's developmental level.

Question 7

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours?&#10;A)A full bladder impedes oxygen flow to the fetus.&#10;B)Frequent voiding prevents bruising of the bladder.&#10;C)Frequent voiding encourages sphincter control.&#10;D)A full bladder can impede fetal descent.&#10;

Accepted Answer

A full bladder can impede fetal descent by physically obstructing the pathway through which the fetus needs to pass during delivery. It can also increase the risk of bladder injury during the delivery process. Encouraging the laboring client to void every 2 hours helps to prevent bladder distention and ensures that the bladder is empty and not obstructing the birth canal.

Question 8

Breathing techniques used in labor provide: (Select all that apply. )&#10;A)A form of anesthesia.&#10;B)A source of relaxation.&#10;C)An increased ability to cope with contractions.&#10;D)A source of distraction.&#10;

Accepted Answer

Breathing techniques can be helpful in providing relaxation and increasing the ability to cope with contractions. They can also serve as a distraction from the pain of labor. However, they do not provide actual anesthesia.

Question 9

Before applying a cord clamp,the nurse assesses the umbilical cord for the presence of vessels.The expected finding is:&#10;A)One artery,one vein.&#10;B)Two arteries,one vein.&#10;C)Two veins,one artery.&#10;D)Two veins,two arteries.&#10;

Accepted Answer

The expected finding when assessing the umbilical cord for the presence of vessels is two arteries and one vein. This is the case for the majority of newborns, and is considered the normal anatomy of the umbilical cord. If only one artery or vein is present, this may indicate a congenital abnormality and warrants further investigation.

Question 10

A client's labor has progressed so rapidly that a precipitous birth is occurring.The nurse should:&#10;A)Go to the nurse's station and immediately call the physician.&#10;B)Run to the delivery room for an emergency birth pack.&#10;C)Stay with the client and ask for auxiliary personnel for assistance.&#10;D)Try to delay the delivery of the infant's head until the physician arrives.&#10;

Accepted Answer

In a precipitous birth, there may not be enough time to call the physician or gather supplies. The nurse should stay with the client and call for assistance from auxiliary personnel. It is also important to monitor the delivery and assist with the baby's delivery if necessary. Trying to delay the delivery can be harmful to both the mother and baby.

Question 11

Oxytocin 20 units was administered at the time of placental delivery.This was done primarily to:&#10;A)Contract the uterus and minimize bleeding.&#10;B)Decrease breast milk production.&#10;C)Decrease maternal blood pressure.&#10;D)Increase maternal blood pressure.&#10;

Accepted Answer

The answer of Oxytocin 20 units was administered at the...

Question 12

Of the most frequent responses to pain,which condition is most likely to impede your client's progress in labor?&#10;A)Increased pulse&#10;B)Elevated blood pressure&#10;C)Muscle tension&#10;D)Increased respirations&#10;

Accepted Answer

The answer of Of the most frequent responses to pain,which...

Question 13

Two hours after delivery,a client's fundus is boggy,and has risen to above the umbilicus.The first action the nurse would take is to:&#10;A)Massage the fundus until firm.&#10;B)Express retained clots.&#10;C)Increase the intravenous solution.&#10;D)Call the physician.&#10;

Accepted Answer

The answer of Two hours after delivery,a client's fundus is...

Question 14

A client delivered 30 minutes ago.Which postpartal assessment finding would require close nursing attention?&#10;A)A soaked perineal pad since the last 15-minute check&#10;B)An edematous perineum&#10;C)A client with tremors&#10;D)A fundus located at the umbilicus&#10;

Accepted Answer

The answer of A client delivered 30 minutes ago.Which postpartal...

Question 15

At 1 minute after birth,the infant has a heart rate of 100 bpm,and is crying vigorously.His limbs are flexed,his trunk is pink,and his feet and hands are cyanotic.The infant cries easily when the soles of his feet are stimulated.The appropriate Apgar score would be _____.

Accepted Answer

The answer of At 1 minute after birth,the infant has...

Deck 19: The Family in Childbirth: Needs and Care