Deck 19: Nursing Care of the Family During Labor and Birth

Question 1

Which technique is an adequate means of controlling the birth of the fetal head during delivery in a vertex presentation?

A) Ritgen maneuver
B) Fundal pressure
C) Lithotomy position
D) De Lee apparatus

Answer 1

Ritgen maneuver

Question 2

Which description of the phases of the first stage of labor is most accurate?

A) Latent: mild, regular contractions; no dilation; bloody show
B) Active: moderate, regular contractions; 4 to 7 cm dilation
C) Lull: no contractions; dilation stable
D) Transition: very strong but irregular contractions; 8 to 10 cm dilation

Answer 2

Active: moderate, regular contractions; 4 to 7 cm dilation

Question 3

Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position?

A) Occiput of the fetus is in a posterior position.
B) Fetus is at or above the ischial spines.
C) Fetus is in a vertex presentation.
D) Membranes have ruptured.

Answer 3

Occiput of the fetus is in a posterior position.

Question 4

The nurse performs a vaginal examination to assess a client's labor progress.Which action should the nurse take next?

A) Perform an examination at least once every hour during the active phase of labor.
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.

Question 5

Through a vaginal examination,the nurse determines that a woman is 4 cm dilated.The external fetal monitor shows uterine contractions every3½ to 4 minutes.The nurse reports this as what stage of labor?

A) First stage, latent phase
B) First stage, active phase
C) First stage, transition phase
D) Second stage, latent phase

Question 6

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

A) Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips
B) Determining the frequency by timing from the end of one contraction to the end of the next contraction
C) Evaluating the intensity by pressing the fingertips into the uterine fundus
D) Assessing uterine contractions every 30 minutes throughout the first stage of labor

Question 7

Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand?

A) Client is considered to be in active labor when she arrives at the facility with contractions.
B) Client can have only her male partner or predesignated doula with her at assessment.
C) Children are not allowed on the labor unit.
D) Non-English speaking client must bring someone to translate.

Question 8

Which clinical finding indicates that the client has reached the second stage of labor?

A) Amniotic membranes rupture.
B) Cervix cannot be felt during a vaginal examination.
C) Woman experiences a strong urge to bear down.
D) Presenting part of the fetus is below the ischial spines.

Question 9

What is the rationale for the administration of an oxytocic (e.g.,Pitocin,Methergine)after expulsion of the placenta?

A) To relieve pain
B) To stimulate uterine contraction
C) To prevent infection
D) To facilitate rest and relaxation

Question 10

When a nulliparous woman telephones the hospital to report that she is in labor,what guidance should the nurse provide or information should the nurse obtain?

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 labor evaluation.
D) Ask the woman to describe why she believes she is in labor.

Question 11

Where is the point of maximal intensity (PMI)of the FHR located?

A) Usually directly over the fetal abdomen
B) In a vertex position, heard above the mother's umbilicus
C) Heard lower and closer to the midline of the mother's abdomen as the fetus descends and internally rotates
D) In a breech position, heard below the mother's umbilicus

Question 12

Which component of the physical examination are Leopold's maneuvers unable to determine?

A) Gender of the fetus
B) Number of fetuses
C) Fetal lie and attitude
D) Degree of the presenting part's descent into the pelvis

Question 13

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC).The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds.They are becoming more regular and are moderate to strong.Based on this information,what would a prudent nurse do next?

A) Immediately notify the woman's primary health care provider.
B) Prepare to administer an oxytocic to stimulate uterine activity.
C) Document the findings because they reflect the expected contraction pattern for the active phase of labor.
D) Prepare the woman for the onset of the second stage of labor.

Question 14

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor?

A) "I passed some thick, pink mucus when I urinated this morning."
B) "My bag of waters just broke."
C) "The contractions in my uterus are getting stronger and closer together."
D) "My baby dropped, and I have to urinate more frequently now."

Question 15

What is the most critical nursing action in caring for the newborn immediately after the birth?

A) Keeping the airway clear
B) Fostering parent-newborn attachment
C) Drying the newborn and wrapping the infant in a blanket
D) Administering eye drops and vitamin K

Question 16

A nulliparous woman has just begun the latent phase of the second stage of her labor.The nurse should anticipate which behavior?

A) A nulliparous woman will experience a strong urge to bear down.
B) Perineal bulging will show.
C) A nulliparous woman will remain quiet with her eyes closed between contractions.
D) The amount of bright red bloody show will increase.

Question 17

The nurse is caring for a client in early labor.Membranes ruptured approximately 2 hours earlier.This client is at increased risk for which complication?

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

Question 18

When assessing a woman in the first stage of labor,which clinical finding will alert the nurse that uterine contractions are effective?

A) Dilation of the cervix
B) Descent of the fetus to -2 station
C) Rupture of the amniotic membranes
D) Increase in bloody show

Question 19

The nurse should be aware of which information related to a woman's intake and output during labor?

A) Traditionally, restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia.
B) Intravenous (IV) fluids are usually necessary to ensure that the laboring 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 quickly follow.

Question 20

A multiparous woman has been in labor for 8 hours.Her membranes have just ruptured.What is the nurse's highest priority in this situation?

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 (FHR) and pattern.

Question 21

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit.The FHR has been normal.Contractions are 5 to 9 minutes apart,20 to 30 seconds in duration,and of mild intensity.Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission).Membranes are intact.What disposition would the nurse anticipate?

A) Admitted and prepared for a cesarean birth
B) Admitted for extended observation
C) Discharged home with a sedative
D) Discharged home to await the onset of true labor

Question 22

When assessing a multiparous woman who has just given birth to an 8-pound 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 is the nurse's assessment of the situation?

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 23

A woman who is gravida 3 para 2 arrives on the intrapartum unit.What is the most important nursing assessment at this time?

A) Contraction pattern, amount of discomfort, and pregnancy history
B) FHR, maternal vital signs, and the woman's nearness to birth
C) Identification of ruptured membranes, woman's gravida and para, and her support person
D) Last food intake, when labor began, and cultural practices the couple desires

Question 24

The first 1 to 2 hours after birth is sometimes referred to as what?

A) Bonding period
B) Third stage of labor
C) Fourth stage of labor
D) Early postpartum period

Question 25

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?

A) Admission to the hospital at the start of labor
B) When accelerations of the FHR are noted
C) On maternal perception of perineal pressure or the urge to bear down
D) When membranes rupture

Question 26

What is the primary rationale for the thorough drying of the infant immediately after birth?

A) Stimulates crying and lung expansion
B) Removes maternal blood from the skin surface
C) Reduces heat loss from evaporation
D) Increases blood supply to the hands and feet

Question 27

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and a tightening of the abdominal muscles.When is it appropriate to instruct the client to use this maneuver?

A) During the second stage to enhance the movement of the fetus
B) During the third stage to help expel the placenta
C) During the fourth stage to expel blood clots
D) Not at all

Question 28

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

A) "Don't worry about it. You'll do fine."
B) "It's normal to be anxious about labor. Let's discuss what makes you afraid."
C) "Labor is scary to think about, but the actual experience isn't."
D) "You can have an epidural. You won't feel anything."

Question 29

Which description of the phases of the second stage of labor is most accurate?

A) Latent phase: Feeling sleepy; fetal station 2+ to 4+; duration of 30 to 45 minutes
B) Active phase: Overwhelmingly strong contractions; Ferguson reflux activated; duration of 5 to 15 minutes
C) Descent phase: Significant increase in contractions; Ferguson reflux activated; average duration varies
D) Transitional phase: Woman "laboring down"; fetal station 0; duration of 15 minutes

Question 30

Which statement concerning the third stage of labor is correct?

A) The placenta eventually detaches itself from a flaccid uterus.
B) An expectant or active approach to managing this stage of labor reduces the risk of complications.
C) It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface.
D) The major risk for women during the third stage is a rapid heart rate.

Question 31

A 25-year-old gravida 3,para 2 client gave birth to a 9-pound,7-ounce boy,4 hours ago after augmentation of labor with oxytocin (Pitocin).She presses her call light,and asks for her nurse right away,stating "I'm bleeding a lot." What is the most likely cause of postpartum hemorrhaging in this client?

A) Retained placental fragments
B) Unrepaired vaginal lacerations
C) Uterine atony
D) Puerperal infection

Question 32

After an emergency birth,the nurse encourages the woman to breastfeed her newborn.What is the primary purpose of this activity?

A) To facilitate maternal-newborn interaction
B) To stimulate the uterus to contract
C) To prevent neonatal hypoglycemia
D) To initiate the lactation cycle

Question 33

As the United States and Canada continue to become more culturally diverse,recognizing a wide range of varying cultural beliefs and practices is increasingly important for the nursing staff.A client is from which country if she requests to have the baby's father in attendance?

A) Mexico
B) China
C) Iran
D) India

Question 34

In recovery,if a woman is asked to either raise her legs (knees extended)off the bed or flex her knees,and then place her feet flat on the bed and raise her buttocks well off the bed,the purpose of this exercise is to assess what?

A) Recovery from epidural or spinal anesthesia
B) Hidden bleeding underneath her
C) Flexibility
D) Whether the woman is a candidate to go home after 6 hours

Question 35

Which collection of risk factors will most likely result in damaging lacerations,including episiotomies?

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

Question 36

A woman who has a history of sexual abuse may have a number of traumatic memories triggered during labor.She may fight the labor process and react with pain or anger.The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner.Which intervention is key for the nurse to use while providing care?

A) Tell the client to relax and that it won't hurt much.
B) Limit the number of procedures that invade her body.
C) Reassure the client that, as the nurse, you know what is best.
D) Allow unlimited care providers to be with the client.

Question 37

A laboring woman is reclining in the supine position.What is the most appropriate nursing action at this time?

A) Ask her to turn to one side.
B) Elevate her feet and legs.
C) Take her blood pressure.
D) Determine whether fetal tachycardia is present.

Question 38

Which characteristic of a uterine contraction is not routinely documented?

A) Frequency: how often contractions occur
B) Intensity: strength of the contraction at its peak
C) Resting tone: tension in the uterine muscle
D) Appearance: shape and height

Question 39

When managing the care of a woman in the second stage of labor,the nurse uses various measures to enhance the progress of fetal descent.Which instruction best describes these measures?

A) Encouraging the woman to try various upright positions, including squatting and standing
B) Telling the woman to start pushing as soon as her cervix is fully dilated
C) Continuing an epidural anesthetic so pain is reduced and the woman can relax
D) Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction

Question 40

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

A) Fetal head is felt at 0 station during vaginal examination.
B) Bloody mucous discharge increases.
C) Vulva bulges and encircles the fetal head.
D) Membranes rupture during a contraction.

Question 41

Women who have participated in childbirth education classes often bring a birth plan with them to the hospital.Which items might this plan include?

A) Presence of companions
B) Clothing to be worn
C) Care and handling of the newborn
D) Medical interventions
E) Date of delivery

Question 42

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 3

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 43

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 1

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 44

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 7

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 45

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 2

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 46

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 5

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 47

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed.Which situations are examples of such an emergency?

A) Nonreassuring or abnormal FHR pattern
B) Inadequate uterine relaxation
C) Vaginal bleeding
D) Prolonged second stage
E) Prolapse of the cord

Question 48

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 6

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 49

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

Step 4

A)After obtaining permission, gently insert the index and middle fingers into the vagina.
B)Explain the findings to the client.
C)Position the woman to prevent supine hypotension.
D)Use sterile gloves and soluble gel for lubrication.
E)Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.