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

Question 1

Which is correct for the nurse to do when preforming vaginal examinations to assess a woman'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 woman in the supine position.
C) Wear two clean gloves for each examination.
D) Discuss the findings with the woman and her partner.

Answer 1

Discuss the findings with the woman and her partner.

Question 2

A pregnant woman is in her third trimester.She asks the nurse to explain how she can tell true labour from false labour.What should the nurse tell her 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 2

They increase with activity,such as ambulation.

Question 3

Why would the nurse expect to administer an oxytocic to a woman after expulsion of her placenta?

A) Relieve pain.
B) Stimulate uterine contraction.
C) Prevent infection.
D) Facilitate rest and relaxation.

Answer 3

Stimulate uterine contraction.

Question 4

When assessing a multiparous woman who has just given birth to a 2500 g boy,the nurse notes that the woman'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 woman is beginning to hemorrhage.
D) Clots have formed in the upper uterine segment.

Question 5

When planning care for a labouring woman whose membranes have ruptured,the nurse recognizes that the woman's risk for which has increased?

A) Intrauterine infection
B) Hemorrhage
C) Precipitous labour
D) Supine hypotension

Question 6

The uterine contractions of a woman early in the active phase of labour are assessed by an internal uterine pressure catheter (IUPC).The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg.The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds.On the basis of this information,what should the nurse do?

A) Notify the woman's primary health care provider immediately.
B) Prepare to administer oxytocin to stimulate uterine activity.
C) Document the findings,as they are considered normal for this phase.
D) Prepare the woman for onset of the second stage of labour.

Question 7

Which alerts the nurse that a woman is in true labour?

A) Passing thick,pink mucus
B) Rupture of membranes
C) Regular,strong contractions with cervical dilation
D) Lightening

Question 8

Through vaginal examination the nurse determines that a woman 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

Question 9

What would the nurse expect from a nulliparous woman who has just begun the second stage of her labour?

A) The woman will experience a strong urge to bear down.
B) The woman will show perineal bulging.
C) The woman will feel tired yet relieved that the first stage is over.
D) The woman will show an increase in bright red bloody show.

Question 10

When a nulliparous woman telephones the hospital to report that she is in labour,what should the nurse do,initially?

A) Tell the woman to stay home until her membranes rupture.
B) Emphasize that food and fluid intake should stop.
C) Arrange for the woman to come to the hospital for labour evaluation.
D) Tell the woman to wait at home until contractions are every 2 to 3 minutes apart.

Question 11

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

A) Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips.
B) Determine the frequency by timing from the end of one contraction to the end of the next contraction.
C) Evaluate the intensity by pressing the fingertips into the uterine fundus.
D) Assess uterine contractions every 30 minutes throughout the first stage of labour.

Question 12

A woman who is 39 weeks pregnant expresses fear about her impending labour and how she will manage.What is the basis for the nurse's response?

A) Offer assurance that the woman will do fine with labour.
B) Indicate that it is normal to be fearful and explore her 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 woman that she will not feel any pain with this method of pain management.

Question 13

What is an expected 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

Question 14

When managing the care of a woman in the second stage of labour,the nurse uses various measures to enhance the progress of fetal descent.Which interventions would be appropriate at this time?

A) Encourage the woman to try various upright positions,including squatting and standing.
B) Tell the woman to start pushing as soon as her cervix is fully dilated.
C) Continue an epidural anaesthetic so that pain is reduced and the woman can relax.
D) Coach the woman to use sustained,10- to 15-second,closed-glottis bearing-down efforts with each contraction.

Question 15

After an emergency birth,the nurse encourages the woman to breastfeed her 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.

Question 16

Which would indicate that a woman has understood education related to the characteristics of true labour?

A) Contractions stop when ambulating.
B) Contractions cause discomfort at the top of the uterus.
C) Contractions are regular and get stronger when ambulating.
D) Contractions are irregular but they are getting stronger.

Question 17

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.

Question 18

Which finding indicates to the 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 woman experiences a strong urge to bear down.
D) The presenting part is below the ischial spines.

Question 19

A multiparous woman has been in labour for 8 hours.Her membranes have just ruptured.What is the nurse's initial response?

A) Prepare the woman for imminent birth.
B) Notify the woman's primary health care provider.
C) Document the characteristics of the fluid.
D) Assess the fetal heart rate and pattern.

Question 20

When assessing a woman in the first stage of labour,the 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

Question 21

When implementing labour and delivery care,the 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) Canadian

Question 22

Which assessment findings would indicate that a woman's membranes are probably ruptured? Select all that apply.Express answer in small letters,followed by a comma and a space-e.g. ,a,b,C

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

Question 23

Which collection of risk factors most likely would result in damaging lacerations?

A) A dark-skinned woman who has had more than one pregnancy,who is going through prolonged second-stage labour,and who is attended by a midwife
B) A reddish-haired mother of two who is going through a breech birth
C) A dark-skinned,first-time mother who is going through a long labour
D) A first-time mother with reddish hair whose rapid labour was overseen by an obstetrician

Question 24

Which suggestion would assist a woman if she is 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.

Question 25

Which generally occurs either before or after the commencement of true labour?

A) The onset of progressive,regular contractions
B) The bloody,or pink,show
C) The spontaneous rupture of membranes
D) Formulation of the woman's plan of care for labour

Question 26

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

Question 27

Which description of the phases of the second stage of labour is accurate?

A) Latent 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

Question 28

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

A) The Ritgen manoeuvre
B) Fundal pressure
C) The lithotomy position
D) The De Lee apparatus

Question 29

Which would alert the nurse that the second stage of labour has begun?

A) The woman 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 woman involuntarily tries to bear down.

Question 30

What should the 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 women during the third stage is a rapid heart rate.

Question 31

Women who have participated in childbirth education classes often bring a "birth bag" or "Lamaze bag" with them to the hospital.Which is a common item that a patient might bring with her for her labour and birth?

A) Candles
B) Tennis balls
C) Bubble bath solution
D) Burning incense for aromatherapy

Question 32

For women who have a history of sexual abuse,the nurse can implement a number of care measures to help her view the childbirth experience in a positive manner.Which intervention would be key 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 her body.
C) Reassure the patient that as the nurse you know what is best.
D) Allow unlimited care providers to be with the patient.

Question 33

Which term is inappropriate for documenting information about uterine contractions?

A) Frequency
B) Intensity
C) Resting tone
D) Appearance

Question 34

What should the nurse know about the point of maximal intensity (PMI)of the fetal heart tone (FHT)?

A) It is usually directly over the fetal abdomen.
B) It is in a vertex position heard above the mother's umbilicus.
C) It is heard lower and closer to the midline as the fetus descends and rotates internally.
D) It is in a breech position heard below the mother's umbilicus.

Question 35

Which statement is true with regard to a woman's intake and output during labour?

A) The tradition of restricting the labouring woman 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 woman stays hydrated.
C) Routine use of an enema empties the rectum and is very helpful for producing a clean,clear delivery.
D) When a nulliparous woman experiences the urge to defecate,it often means birth will follow quickly.

Question 36

Which should the nurse be aware of with regard to the procedures and criteria for admitting a woman to the hospital labour unit?

A) She is not considered to be in true labour (according to the Emergency Medical Treatment and Active Labor Act [EMTALA])until a qualified health care provider says she is.
B) She can have only her male partner or predesignated doula with her at assessment.
C) Her weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion and Caesarean birth.
D) The nurse should listen politely to the woman's previous birthing experiences but should keep in mind that each birth is a unique experience.

Question 37

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;5- 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