Deck 18: The Family in Childbirth: Needs and Care

Question 1

The client in labor arrives at the birthing unit with her partner. Which step of the admission process should be completed first?
1) Welcoming the couple
2) The sterile vaginal examination
3) Auscultation of the fetal heart rate
4) Checking for ruptured membranes

Answer 1

1

Question 2

What should be the nurse's priority when caring for an adolescent in labor?
1) Support persons
2) Developmental level
3) Cultural background
4) Plans for keeping the infant

Answer 2

2

Question 3

Upon delivery of the newborn, which action most promotes parental attachment?
1) Placing the newborn under the radiant warmer
2) Placing the newborn on the maternal abdomen
3) Taking the newborn to the nursery for the initial assessment
4) Allowing the mother a chance to rest immediately after delivery

Answer 3

2

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.
1) Kussmaul breathing
2) Abdominal breathing
3) Slow-paced breathing
4) Pant-pant-blow breathing
5) Modified-paced breathing

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.
1) Edema
2) Vomiting
3) Dehydration
4) Preeclampsia
5) Insulin resistance

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?
1) Rescue breathing and stimulation
2) Stimulation and resuscitative efforts
3) Nasopharyngeal suctioning and blow-by oxygen
4) Oxygen via face mask and endotracheal suctioning

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?
1) Insist that he leave the room for at least the next hour.
2) Offer to remain with his partner while he takes a break.
3) Suggest that the patient's mother might be of more help.
4) Tell him he is not being as effective as he was and that he needs to let someone else take over.

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.
1) Have long-sleeved gowns available.
2) Offer warm fluids to sip during the labor process.
3) Ask the spouse for permission before examining the client.
4) Ensure female healthcare providers examine the client.
5) Provide the spouse with water to cleanse the newborn upon birth.

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.
1) Drop in blood pressure
2) Increased bloody show
3) Bulging of the perineum
4) Subjective feeling of faintness
5) Uncontrollable urge to bear down

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?
1) Obtain a clean-catch urine specimen.
2) Apply an internal fetal scalp electrode.
3) Keep the patient on bed rest at this time.
4) Encourage the husband to remain in the room.

Question 11

What is the purpose for the client in labor to utilize different breathing techniques? Select all that apply.
1) Reduces pain
2) A source of relaxation
3) A source of distraction
4) Speeds up the delivery process
5) An increased ability to cope with contractions

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.
1) Protein of +1 in urine
2) Maternal pulse of 160
3) Blood pressure of 120/80
4) Odorless, clear fluid on underwear
5) Fetal heart rate (FHR) of 130 with average variability

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.
1) Provide simple and concrete explanations.
2) Stay with the client during the labor process.
3) Provide soothing encouragement during the transition phase.
4) Provide positive reinforcement with a nonjudgmental manner.
5) Remain calm and provide clear directions during the second stage.

Question 14

A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action?
1) Assess blood pressure and check for proteinuria.
2) Obtain a Social Services referral to discuss adoption.
3) Determine who might be the father of the baby for paternity testing.
4) Ask the client what kind of birthing experience she would like to have.

Question 15

The nurse encounters a woman giving birth at the local shopping mall. What should the nurse do first?
1) Visualize the perineum.
2) Apply counterpressure to the perineum.
3) Ask a bystander for a dry piece of clothing.
4) Determine if the membranes have ruptured.

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?"
1) "A vaginal examination is performed if delivery appears to be imminent."
2) "Her prenatal record is reviewed for indications of domestic abuse."
3) "She will be positioned supine to facilitate a normal blood pressure."
4) "A urine specimen is obtained by catheter to check for protein and ketones."

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?
1) 6
2) 7
3) 8
4) 9

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?
1) Instruct the client to push.
2) Suction the baby's mouth, throat, and nose.
3) Exert upward traction to the fetal head to facilitate birth of the posterior shoulder.
4) Exert downward traction on the fetal head to facilitate movement of the anterior shoulder.

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?
1) "After delivery, the newborn is immediately placed in skin-to-skin contact with the mother."
2) "Immediately after delivery, the newborn is wrapped in a blanket and placed on the mother's chest."
3) "If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat."
4) "If a radiant-heated unit is used to keep the neonate warm, the neonate is dried, wrapped in a dry blanket, and placed under the radiant heat."

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?
1) "You can drink black coffee."
2) "You may have coffee with creamer."
3) "You are only allowed to drink water right now."
4) "Since you are having surgery today, you're not allowed to have anything to eat or drink."