Question 1

The client in labor arrives at the birthing unit with her partner. Which step of the admission process should be completed first?

Accepted Answer

Welcoming the couple is the first step in the admission process to create a supportive and respectful environment, which is essential for establishing trust and communication between the healthcare team and the client.

Question 2

What should be the nurse's priority when caring for an adolescent in labor?

Accepted Answer

The nurse's priority when caring for an adolescent in labor should be to consider the adolescent's developmental level. Adolescents undergoing pregnancy and childbirth may have limited knowledge and understanding of the process and their options for care. The nurse should provide education and support tailored to the adolescent's age, cognitive level, and emotional needs. Support persons, cultural background, and plans for keeping the infant are also important considerations but should not take precedence over the adolescent's developmental needs.

Question 3

Upon delivery of the newborn, which action most promotes parental attachment?

Accepted Answer

Placing the newborn on the maternal abdomen immediately after delivery promotes skin-to-skin contact, which has been shown to promote parental attachment and bonding. This also helps regulate the newborn's body temperature and stabilizes their heart rate and breathing.

Question 4

A client in labor did not attend prenatal classes and is experiencing severe pain. In which breathing technique should the nurse instruct the client to help with relaxation and control? Select all that apply.

Accepted Answer

The answer of A client in labor did not attend...

Question 5

Ketones are present in a urine specimen of a client in the beginning phases of labor. What should the nurse consider as the reason for this laboratory finding? Select all that apply.

Accepted Answer

Ketones in urine can be caused by vomiting, dehydration, and insulin resistance. Edema and preeclampsia are not typically associated with the presence of ketones in urine during labor.

Question 6

Five minutes after delivery, the neonate's body is pink with blue extremities. The heart rate is
150) The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate?

Accepted Answer

The infant's good respiratory effort and vigorous cry indicate that he is breathing adequately, so resuscitative efforts are not necessary. However, because the neonate has blue extremities, blow-by oxygen is appropriate to help with oxygenation. Nasopharyngeal suctioning may also help clear any amniotic fluid or mucus, which could improve oxygenation. The infant's withdrawal reflex indicates that he is neurologically intact, so additional stimulation or rescue breathing are not necessary. Endotracheal suctioning and oxygen via face mask would be invasive interventions that are not indicated at this time.

Question 7

An expectant father has been at the bedside of his laboring partner for more than 12 hours. What would be an appropriate nursing intervention?

Accepted Answer

Offering to remain with the patient while the father takes a break would allow him to recharge and be more present and effective for his partner during her labor. Insisting that he leave or suggesting someone else may cause added stress and potentially interfere with their bonding experience as a family.

Question 8

The nurse is preparing to admit a pregnant client who is Muslim to the birthing center. What should the nurse keep in mind during the labor process? Select all that apply.

Accepted Answer

The answer of The nurse is preparing to admit a...

Question 9

The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? Select all that apply.

Accepted Answer

Increased bloody show, bulging of the perineum, and an uncontrollable urge to bear down are all signs that birth is imminent during the second stage of labor.

Question 10

The client in labor has moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to
150) Which nursing action has the highest priority?

Accepted Answer

Given the situation, keeping the patient on bed rest is the highest priority. This is because the membranes have already ruptured, increasing the risk of infection and potentially complicating the labor if the patient is too active. Bed rest can help manage the progression of labor under these circumstances, ensuring both maternal and fetal well-being.

Question 11

What is the purpose for the client in labor to utilize different breathing techniques? Select all that apply.

Accepted Answer

The answer of What is the purpose for the client...

Question 12

A client states that her water broke 2 hours ago. What findings should the nurse identify as indications of normal labor? Select all that apply.

Accepted Answer

The answer of A client states that her water broke...

Question 13

The nurse is caring for a 13-year-old client who is in labor. What actions should the nurse take to support this client's needs? Select all that apply.

Accepted Answer

The answer of The nurse is caring for a 13-year-old...

Question 14

A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action?

Accepted Answer

The most important nursing action in this situation is to assess the client's blood pressure and check for proteinuria, as these are indications of preeclampsia or eclampsia, which can be life-threatening for the mother and baby. Once the client's medical condition is stabilized, the nurse can discuss options for the birth and potential social services referrals. Paternity testing is not a priority at this time.

Question 15

The nurse encounters a woman giving birth at the local shopping mall. What should the nurse do first?

Accepted Answer

Visualizing the perineum is the first step the nurse should take to assess the situation, including how far the labor has progressed and if the baby is indeed coming at that moment. This initial assessment is crucial for determining the next steps in care.

Question 16

The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective?"

Accepted Answer

The answer of The nurse is orienting a new graduate...

Question 17

One minute after delivery the following is assessed in a neonate: heart rate 120 beats per minute, vigorous cry, actively moving, resists attempts to straighten an arm, facial grimace with sole flicking, body pink, extremities blue. What Apgar score should the nurse assign to this infant?

Accepted Answer

The infant scores 2 for appearance (body pink) and 1 for pulse (120 bpm), respiration (vigorous cry), reflex irritability (facial grimace with sole flicking), and muscle tone (actively moving and resisting attempts to straighten an arm), which adds up to a total score of 8.

Question 18

The nurse is assisting with a precipitous birth. In which order should the nurse perform the following actions after the birth of the fetal head?
A) Instruct the client to push.
B) Suction the baby's mouth, throat, and nose.
C) Exert upward traction to the fetal head to facilitate birth of the posterior shoulder.
D) Exert downward traction on the fetal head to facilitate movement of the anterior shoulder.

Accepted Answer

The answer of The nurse is assisting with a precipitous...

Question 19

The neonatal nurse specialist is describing neonatal care to nursing students. What statement should the specialist include when describing a proper method for preventing heat loss in the neonate?

Accepted Answer

The answer of The neonatal nurse specialist is describing neonatal...

Question 20

A client scheduled for elective cesarean birth in 4 hours asks for a sip of coffee with creamer. How should the nurse respond?

Accepted Answer

It is recommended for clients scheduled for elective cesarean birth to have nothing to eat or drink for several hours prior to the procedure to prevent aspiration during anesthesia. Black coffee without creamer or any added sugars may be allowed in some cases, but it is best to follow the healthcare provider's specific instructions.

Quiz 18: The Family in Childbirth: Needs and Care