Deck 24: The Family in Childbirth: Needs and Care

Question 1

The primiparous patient is being admitted to the birthing unit. As the nurse begins the assessment, the patient's partner asks why the baby's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching?

A) "The baby's heart rate will vary between 110 and 160."
B) "The heart rate is monitored to see whether the baby is tolerating labor."
C) "By listening to the heart, we can tell the gender of the baby."
D) "After listening to the heart rate, you will contact the midwife."

Answer 1

"By listening to the heart, we can tell the gender of the baby."

Question 2

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

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

Answer 2

Offer to remain with his partner while he takes a break.

Question 3

A multiparous patient is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The patient asks what part of labor she is in. The nurse should inform the patient that she is in the:

A) Early phase.
B) Active phase.
C) Transition phase.
D) Fourth stage.

Answer 3

Transition phase.

Question 4

The laboring patient and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first?

A) The sterile vaginal exam
B) Welcoming the couple
C) Auscultation of the fetal heart rate
D) Checking for ruptured membranes

Question 5

A patient who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful?

A) Talk to the patient the entire time.
B) Turn on the television to distract the patient.
C) Stand next to the bed with hands on the railing next to the patient.
D) Sit silently in the room away from the bed.

Question 6

The nurse is assessing a patient who thinks she is in labor. Which findings would positively confirm the woman is in labor?

A) She is contracting every 5 minutes for 60 seconds.
B) Her cervix has dilated from 2 to 4 centimeters.
C) Her membranes have ruptured.
D) The fetal head is engaged.
E) The contractions are starting in the back and radiating around to the front of the abdomen with uterine relaxation between contractions.

Question 7

A 22-year-old single patient, G1, P0, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of labor?

A) Fear/Anxiety related to discomfort of labor and unknown labor outcome
B) Deficient Knowledge related to lack of information about involution process
C) Acute Pain related to uterine contractions, cervical dilatation, and fetal descent
D) Acute Pain related to perineal trauma
E) Compromised Family Coping related to labor process

Question 8

The nurse is aware of the different breathing techniques that are used during labor. Breathing techniques used in labor:

A) Are a form of anesthesia.
B) Are a source of relaxation.
C) Increase the ability to cope with contractions.
D) Are a source of distraction.
E) Comprise chest breathing or abdominal breathing.

Question 9

The laboring primiparous patient is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the patient's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this patient?

A) Health-seeking Behaviors related to increased pain level
B) Acute Pain related to contractions and the birth process
C) Compromised Family Coping related to birth process
D) Deficient Knowledge related to lack of information about relaxation

Question 10

By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily:

A) Recognizing the patient as an active participant in her own care.
B) Attempting to correct any misinformation the patient might have received.
C) Acting as an advocate for the patient.
D) Establishing rapport with the patient.

Question 11

The patient presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the patient's temperature?

A) Every hour
B) Every 2 hours
C) Every 4 hours
D) Every shift

Question 12

Two hours after delivery, a patient's fundus is boggy and has risen to above the umbilicus. The first action the nurse would take is to:

A) Massage the fundus until firm.
B) Express retained clots.
C) Increase the intravenous solution.
D) Call the physician.

Question 13

The laboring patient is having 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?

A) Encourage the husband to remain in the room.
B) Keep the patient on bed rest at this time.
C) Apply an internal fetal scalp electrode.
D) Obtain a clean-catch urine specimen.

Question 14

The primiparous patient has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this patient?

A) Encourage the patient to vocalize during contractions.
B) Perform vaginal exams only between contractions.
C) Provide a CD of soft music with sounds of nature.
D) Offer to teach the partner how to massage tense muscles.

Question 15

The laboring patient presses the call light and reports that her water has just broken. The nurse's first action would be to:

A) Check fetal heart tones.
B) Encourage the mother to go for a walk.
C) Change bed linens.
D) Call the physician.

Question 16

The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching has been effective? "When a patient arrives in labor:

A) "A urine specimen is obtained by catheter to check for protein and ketones."
B) "She will be positioned supine to facilitate a normal blood pressure."
C) "Her prenatal record is reviewed for indications of domestic abuse."
D) "A vaginal exam is performed unless birth appears to be imminent."

Question 17

Why is it important for the nurse to assess the bladder regularly and encourage the laboring patient to void every 2 hours?

A) A full bladder impedes oxygen flow to the fetus.
B) Frequent voiding prevents bruising of the bladder.
C) Frequent voiding encourages sphincter control.
D) A full bladder can impede fetal descent.

Question 18

The labor and birth nurse is admitting a patient. The nurse's assessment includes asking the patient whom she would like to have present for the labor and birth, and what the patient would prefer to wear. The patient's partner asks the nurse the reason for these questions. The nurse's best response would be:

A) "These questions are asked of all women. It's no big deal."
B) "I'd prefer that your partner ask me all the questions, not you."
C) "A patient's preferences for her birth are important for me to understand."
D) "Many women have beliefs about childbearing that affect these choices."
E) "I'm gathering information that the nurses will use after the birth."

Question 19

The nurse has completed the physical assessment of a patient in early labor, and proceeds with the social assessment. A social history of the patient would include:

A) Use of drugs and alcohol.
B) Ethnicity and religion.
C) Current living situation.
D) Type of insurance.
E) Available community resources.

Question 20

The laboring patient 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:

A) Hyperventilation.
B) Seizure auras.
C) Imminent birth.
D) Anxiety.

Question 21

Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is:

A) Placing the newborn under the radiant warmer.
B) Placing the newborn on the mother's abdomen.
C) Allowing the mother a chance to rest immediately after delivery.
D) Taking the newborn to the nursery for the initial assessment.

Question 22

A patient delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention?

A) A soaked perineal pad since the last 15-minute check
B) An edematous perineum
C) The patient experiencing tremors
D) A fundus located at the umbilicus

Question 23

A full-term infant has just been born. Which interventions should the nurse perform first?

A) Placing the infant in a radiant-heated unit
B) Suctioning the infant with a bulb syringe
C) Wrapping the infant in a blanket
D) Evaluating the newborn using the Apgar system
E) Offering a feeding of 5% glucose water

Question 24

Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. The nurse should reply, "I'm checking the blood vessels in the cord to see whether it has:

A) "One artery and one vein."
B) "Two arteries and one vein."
C) "Two veins and one artery."
D) "Two arteries and two veins."

Question 25

The nurse administered oxytocin 20 units at the time of placental delivery. This was done primarily to:

A) Contract the uterus and minimize bleeding.
B) Decrease breast milk production.
C) Decrease maternal blood pressure.
D) Increase maternal blood pressure.

Question 26

As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be:

A) Cultural background.
B) Plans for keeping the infant.
C) Support persons.
D) Developmental level.

Question 27

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

A) Apply counterpressure to the perineum.
B) Ask a bystander for a dry piece of clothing.
C) Visualize the perineum.
D) Determine whether the membranes have ruptured.

Question 28

At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score?

A) 7
B) 8
C) 9
D) 10

Question 29

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score?

A) 7
B) 8
C) 9
D) 10

Question 30

When caring for a 13-year-old patient in labor, the nurse provides sensitive care by:

A) Using simple and concrete instructions.
B) Providing soothing encouragement and comfort measures.
C) Making all decisions for the patient when she expresses a feeling of helplessness.
D) Deciding whom the patient should allow in the room.
E) Providing encouragement and support of the patient's decisions.

Question 31

A young adolescent is transferred to the labor and delivery unit from the emergency department. The patient is in active labor, but did not know she was pregnant. The most important nursing action is to:

A) Determine who might be the father of the baby for paternity testing.
B) Ask the patient what kind of birthing experience she would like to have.
C) Assess blood pressure and check for proteinuria.
D) Obtain a Social Services referral to discuss adoption.

Question 32

A patient's labor has progressed so rapidly that a precipitous birth is occurring. The nurse should:

A) Go to the nurse's station and immediately call the physician.
B) Run to the delivery room for an emergency birth pack.
C) Stay with the patient and ask for auxiliary personnel for assistance.
D) Try to delay the delivery of the infant's head until the physician arrives.