Question 1

The nurse who performs vaginal examinations to assess a woman's progress in labor should:

Accepted Answer

The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider.A vaginal examination should be performed only when indicated by the status of the woman and her fetus.The woman should be positioned to avoid supine hypotension.The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.

Question 2

The most critical nursing action in caring for the newborn immediately after birth is:

Accepted Answer

The care given immediately after the birth focuses on assessing and stabilizing the newborn.Although fostering parent-infant attachment is an important task for the nurse,it is not the most critical nursing action in caring for the newborn immediately after birth.The nursing activities would be (in order of importance)to maintain a patent airway,support respiratory effort,and prevent cold stress by drying the newborn and covering the infant with a warmed blanket or placing the newborn under a radiant warmer.After the newborn has been stabilized,the nurse assesses the newborn's physical condition,weighs and measures the newborn,administers prophylactic eye ointment and a vitamin K injection,affixes an identification bracelet,wraps the newborn in warm blankets,and then gives the infant to the partner or mother when he or she is ready.

Question 3

The nurse knows that the second stage of labor,the descent phase,has begun when:

Accepted Answer

During the descent phase of the second stage of labor,the woman may experience an increase in the urge to bear down.Rupture of membranes has no significance in determining the stage of labor.The second stage of labor begins with full cervical dilation.Many women may have an urge to bear down when the presenting part is below the level of the ischial spines.This can occur during the first stage of labor,as early as 5-cm dilation.

Question 4

When assessing a woman in the first stage of labor,the nurse recognizes that the most conclusive sign that uterine contractions are effective would be:

Accepted Answer

The vaginal examination reveals whether the woman is in true labor.Cervical change,especially dilation,in the presence of adequate labor indicates that the woman is in true labor.Descent of the fetus,or engagement,may occur before labor.Rupture of membranes may occur with or without the presence of labor.Bloody show may indicate slow,progressive cervical change (e.g.,effacement)in both true and false labor.

Question 5

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

Accepted Answer

The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips.Many women may experience labor pain in the lower segment of the uterus that may be unrelated to the firmness of the contraction detectable in the uterine fundus.The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction.Assessment of uterine activity is performed in intervals based on the stage of labor.As labor progresses this assessment is performed more frequently.

Question 6

Through vaginal examination the nurse determines that a woman is 4 cm dilated,and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes.The nurse would report this as:

Accepted Answer

The first stage,active phase of maternal progress indicates that the woman is in the active phase of the first stage of labor.During the latent phase of the first stage of labor,the expected maternal progress would be 0 to 3 cm dilation with contractions every 5 to 30 minutes.During the transition phase of the first stage of labor,the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes.During the latent phase of the second stage of labor,the woman is completely dilated and experiences a restful period of "laboring down."

Question 7

For the labor nurse,care of the expectant mother begins with any or all of these situations,with the exception of:

Accepted Answer

Labor care begins when progressive,regular contractions begin; the blood-tinged mucoid vaginal discharge appears; or fluid is discharged from the vagina.The woman and nurse can formulate their plan of care before labor or during treatment.

Question 8

Nurses can help their patients by keeping them informed about the distinctive stages of labor.Which description of the phases of the first stage of labor is accurate?

Accepted Answer

The active phase is characterized by moderate,regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours.The latent phase is characterized by mild-to-moderate,irregular contractions; dilation up to 3 cm; brownish-to-pale pink mucus,and a duration of 6 to 8 hours.No official "lull" phase exists in the first stage.The transition phase is characterized by strong to very strong,regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes.

Question 9

A multiparous woman has been in labor for 8 hours.Her membranes have just ruptured.The nurse's initial response would be to:

Accepted Answer

The umbilical cord may prolapse when the membranes rupture.The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being,and the findings should be documented.Rupture of membranes (ROM)may increase the intensity and frequency of the uterine contractions,but it does not indicate that birth is imminent.The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed.The nurse's priority is to assess fetal well-being.The nurse should document the characteristics of the amniotic fluid,but the initial response is to assess fetal well-being and the response to ROM.

Question 10

When a nulliparous woman telephones the hospital to report that she is in labor,the nurse initially should:

Accepted Answer

Assessment begins at the first contact with the woman,whether by telephone or in person.By asking the woman to describe her signs and symptoms,the nurse can begin the assessment and gather data.The amniotic membranes may or may not spontaneously rupture during labor.The patient may be instructed to stay home until the uterine contractions become strong and regular.The nurse may want to discuss the appropriate oral intake for early labor such as light foods or clear liquids,depending on the preference of the patient or her primary health care provider.Before instructing the woman to come to the hospital,the nurse should initiate the assessment during the telephone interview.

Question 11

The nurse teaches a pregnant woman about the characteristics of true labor contractions.The nurse evaluates the woman's understanding of the instructions when she states,"True labor contractions will:

Accepted Answer

True labor contractions occur regularly,becoming stronger,lasting longer,and occurring closer together.They may become intense during walking and continue despite comfort measures.Typically true labor contractions are felt in the lower back,radiating to the lower portion of the abdomen.During false labor,contractions tend to be irregular and felt in the abdomen above the navel.Typically the contractions often stop with walking or a change of position.

Question 12

The nurse recognizes that a woman is in true labor when she states:

Accepted Answer

Regular,strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.Loss of the mucous plug (operculum)often occurs during the first stage of labor or before the onset of labor,but it is not the indicator of true labor.Spontaneous rupture of membranes often occurs during the first stage of labor,but it is not the indicator of true labor.The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor,but this is not the indicator of true labor.

Question 13

When planning care for a laboring woman whose membranes have ruptured,the nurse recognizes that the woman's risk for _________________________ has increased.

Accepted Answer

When the membranes rupture,microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis.Rupture of membranes (ROM)is not associated with fetal or maternal bleeding.Although ROM may increase the intensity of contractions and facilitate active labor,it does not result in precipitous labor.ROM has no correlation with supine hypotension.

Question 14

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.These measures include:

Accepted Answer

Upright positions and squatting both may enhance the progress of fetal descent.Many factors dictate when a woman will begin pushing.Complete cervical dilation is necessary,but it is only one factor.If the fetal head is still in a higher pelvic station,the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent,thereby reducing the amount of pushing needed)if the woman is able.The epidural may mask the sensations and muscle control needed for the woman to push effectively.Closed glottic breathing may trigger the Valsalva maneuver,which increases intrathoracic and cardiovascular pressures,reducing cardiac output and inhibiting perfusion of the uterus and placenta.In addition,holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia.

Question 15

When assessing a multiparous woman who has just given birth to an 8-lb 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.The nurse concludes that:

Accepted Answer

Placental separation is indicated by a firmly contracting uterus,a change in the uterus from a discoid to a globular ovoid shape,a sudden gush of dark red blood from the introitus,an apparent lengthening of the umbilical cord,and a finding of vaginal fullness.Cervical tears that do not extend to the vagina result in minimal blood loss.Signs of hemorrhage are a boggy uterus,bright red vaginal bleeding,alterations in vital signs,pallor,lightheadedness,restlessness,decreased urinary output,and alteration in the level of consciousness.If clots have formed in the upper uterine segment,the nurse would expect to find the uterus boggy and displaced to the side.

Question 16

The nurse expects to administer an oxytocic (e.g.,Pitocin,Methergine)to a woman after expulsion of her placenta to:

Accepted Answer

Oxytocics stimulate uterine contractions,which reduce blood loss after the third stage of labor.Oxytocics are not used to treat pain or prevent infection.They cause the uterus to contract,which reduces blood loss.Oxytocics do not facilitate rest and relaxation.

Question 17

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage.The nurse's best response is:

Accepted Answer

"It's normal to be anxious about labor.Let's discuss what makes you afraid" allows the woman to share her concerns with the nurse and is a therapeutic communication tool."Don't worry about it.You'll do fine" negates the woman's fears and is not therapeutic."Labor is scary to think about,but the actual experience isn't" negates the woman's fears and offers a false sense of security.It is not true that every woman may have an epidural.A number of criteria must be met for use of an epidural.Furthermore,many women still experience the feeling of pressure with an epidural.

Question 18

A nulliparous woman who has just begun the second stage of her labor would most likely:

Accepted Answer

Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because "the worst is over." During the latent phase of the second stage of labor,the urge to bear down often is absent or only slight during the acme of contractions.Perineal bulging occurs during the transition phase of the second stage of labor,not at the beginning of the second stage.An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

Question 19

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

Accepted Answer

Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.Breastfeeding facilitates maternal-newborn interaction,but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth.The primary intervention for preventing neonatal hypoglycemia is thermoregulation.Cold stress can result in hypoglycemia.The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin,which prevents hemorrhage.Breastfeeding is encouraged to initiate the lactation cycle,but it is not the primary reason for this activity after an emergency birth.

Question 20

A pregnant woman is in her third trimester.She asks the nurse to explain how she can tell true labor from false labor.The nurse would explain that "true" labor contractions:

Accepted Answer

True labor contractions become more intense with walking.False labor contractions often stop with walking or position changes.Rupture of membranes may occur before or during labor.True labor contractions are regular.

Quiz 16: Nursing Care of the Family During Labor and Birth