Question 1

A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, the nurse assesses the most likely explanation for the woman's change in behavior is that:

Accepted Answer

If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

Question 2

The nurse explains that the function of contractions during the second stage of labor is to:

Accepted Answer

The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant.

Question 3

The nurse would coach the laboring woman with a fully dilated cervix to push by saying:

Accepted Answer

When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, then take another deep breath and push while exhaling.

Question 4

Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. This presentation is referred to as:

Accepted Answer

In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

Question 5

The relaxation phase between contractions is important because the:

Accepted Answer

Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

Question 6

One hour postdelivery the nurse notes the new mother has saturated three perineal pads. The nurse should:

Accepted Answer

Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

Question 7

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurse's initial action is to:

Accepted Answer

Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

Question 8

The nurse explains that the third stage of labor ends with:

Accepted Answer

The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.

Question 9

When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates:

Accepted Answer

Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.

Question 10

The nurse caring for a woman in the first stage of labor reminds the patient that contractions during this stage of labor:

Accepted Answer

The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

Question 11

The most important nursing activity during the fourth stage of labor is to:

Accepted Answer

Immediately after giving birth, every woman is assessed for signs of hemorrhage.

Question 12

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of:

Accepted Answer

Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

Question 13

To relieve perineal bruising and edema following delivery the nurse should:

Accepted Answer

An ice pack can be placed on the mother's perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours following delivery.

Question 14

The nurse measures the frequency of a laboring woman's contractions by noting:

Accepted Answer

The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.

Question 15

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by:

Accepted Answer

In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

Question 16

It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. The nurse would record this presentation as:

Accepted Answer

When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.

Question 17

The nurse recognizes the contraction duration and interval that could result in fetal compromise is:

Accepted Answer

Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

Question 18

While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. The nurse's most informative response would be that the woman should come when she:

Accepted Answer

Ruptured membranes are an indication that the woman should go to the hospital or birthing center.

Question 19

During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may:

Accepted Answer

A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.

Question 20

When the nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" The nurse should:

Accepted Answer

If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

Quiz 6: Nursing Care of Mother and Infant During Labor and Birth