Question 1

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

Accepted Answer

D

Question 2

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently?

Accepted Answer

A full bladder can impede fetal descent by taking up space in the pelvis, which can interfere with the baby's ability to move down the birth canal during labor.

Question 3

The nurse is assessing the comfort of the parents during the third stage of labor. Which finding(s) indicate that the parents feel comfortable during this stage?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A, B

Question 4

The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 c m 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 described, keeping the client on bed rest is the highest priority. The client's membranes have ruptured, increasing the risk of infection and potentially complicating the labor process. Bed rest can help manage these risks and support the progression of labor under close monitoring. The other options, while potentially valuable in certain contexts, do not address the immediate concerns related to the laboring process and the risk of infection following membrane rupture.

Question 5

A client 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 c m dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor?

Accepted Answer

The transition phase of labor is characterized by cervical dilation from 8 to 10 cm, 100% effacement, and more intense contractions. This phase is the final part of the first stage of labor, leading up to the point where the mother is ready to push and deliver the baby.

Question 6

By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following?

Accepted Answer

By inquiring about the expectations and plans, the nurse is recognizing the client as an active participant in her own care, which is essential for providing patient-centered care.

Question 7

The laboring client is at 7 c m, 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 client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client?

Accepted Answer

The client's recent behavior change, from using relaxation and breathing techniques successfully to writhing and screaming, indicates acute pain related to the progression of labor, including uterine contractions, cervical dilation, and fetal descent. This is a normal part of labor as it intensifies, especially as she is at 7 cm dilation and experiencing strong contractions every 3 minutes.

Question 8

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

Accepted Answer

Massaging the fundus until it becomes firm is the first action a nurse should take when the fundus is boggy and has risen above the umbilicus, as this can help contract the uterus and control postpartum hemorrhage.

Question 9

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

Accepted Answer

Welcoming the couple is the first step in the admission process to the birthing unit. It helps in establishing a rapport and making the couple feel comfortable and supported, which is crucial for a positive birthing experience.

Question 10

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

Accepted Answer

Teaching the partner how to massage tense muscles can provide physical comfort and support during labor, which is crucial for a client aiming for an unmedicated birth.

Question 11

A client 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?

Accepted Answer

Standing next to the bed with hands on the railing next to the client provides a presence of support and readiness to assist, which can be comforting during the intense transition stage of labor, especially in the absence of the partner.

Question 12

The laboring client 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 which of the following?

Accepted Answer

These symptoms are indicative of hyperventilation, which can occur during labor due to rapid and shallow breathing. This leads to decreased carbon dioxide levels in the blood, causing tingling and numbness in fingers and toes, dizziness, and visual disturbances.

Question 13

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of The client presents to the labor and...

Question 14

The nurse is caring for a client and her spouse during the third stage of labor. Which action(s) support initial parental-newborn attachment at this time?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

The answer of The nurse is caring for a client...

Question 15

The nurse is reviewing the contents of the birthing unit's emergency pack for use in case of a precipitous birth. Which item(s) should the nurse ensure is (are) included in the pack?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

These items are all necessary for use in case of a precipitous birth. The sterile drape is used to create a sterile field, the bulb syringe is used to suction the baby's airway, the two sterile clamps are used to clamp the umbilical cord, and the sterile gloves are used to protect the nurse's hands.

Question 16

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done?

Accepted Answer

Oxytocin is administered to contract the uterus and minimize postpartum bleeding by promoting uterine contractions, which helps to prevent postpartum hemorrhage.

Question 17

The nurse is assessing the emotional state of a client following the delivery of her newborn. Which response by the client requires further follow up by the nurse?

Accepted Answer

Withdrawn behavior in a new mother could indicate postpartum depression or other emotional health issues, requiring further assessment and possibly intervention.

Question 18

The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

Understanding a client's preferences and beliefs about childbirth is important for providing personalized and respectful care.

Question 19

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

Accepted Answer

The statement "By listening to the heart, we can tell the gender of the fetus" indicates a misunderstanding. Fetal heart rate monitoring is used to assess the fetus's well-being and tolerance of labor, not to determine gender.

Question 20

The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be?

Accepted Answer

When a laboring client's water breaks, the first action should be to check fetal heart tones to assess the well-being of the fetus, as there is a risk of cord prolapse or other complications following rupture of membranes.

Quiz 21: The Family in Childbirth: Needs and Care