Ch 26: Labor and Delivery

34. The nurse explains to the patient whose membranes ruptured an hour ago that delivery is usually accomplished in to hours postrupture.

ANS: 18, 24 eighteen, twenty-four After the rupture of membranes, labor is usually accomplished in 18 to 24 hours. REF: Page 806 TOP: Ruptured membranes

35. The nurse clarifies to a primigravida that her pelvis is of the android type, which usually means the delivery will be a .

ANS: cesarean The narrow outlet of the android-type pelvis usually requires a cesarean delivery. REF: Page 807, Table 26-2 TOP: Android pelvis

36. The nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mother's to demonstrate a lie.

ANS: longitudinal A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other. REF: Page 809 TOP: Fetal lie

11. During the second stage of labor, the nurse should monitor the fetal heart rate every: a. 5 minutes. b. 10 minutes. c. 15 minutes. d. 20 minutes.

ANS: A Fetal heart rate should be assessed every 5 minutes during the second stage of labor. REF: Page 819 TOP: Fetal heart rate

10. Using Leopold's maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus. The fetal position is: a. right occiput anterior (ROA), vertex. b. left occiput anterior (LOA), vertex. c. right occiput transverse (ROT), breech. d. left occiput anterior (LOA) breech.

ANS: A Fetal position can be determined by Leopold's maneuver, which defines the relationship of presenting part to maternal pelvis quadrant. REF: Pages 809-810, Figures 26-3, 26-4 and 26-5 TOP: Fetal position

25. The physician has decided to induce labor with prostaglandin gel and an amniotomy. The nurse assures the patient that labor will probably start in: a. 1 hour. b. 4 hours. c. 8 hours. d. 12 hours.

ANS: A Medically approved methods of inducing labor include prostaglandin gel application that usually induces labor in 1 hour or less. REF: Page 837 TOP: Induction

27. As the second stage of labor begins, the mother has an urge to push. The nurse encourages her to use her abdominal muscles to assist with pushing because: a. the cervix is completely dilated. b. the baby needs to be brought down. c. the cervix needs to be enlarged. d. effacement needs to be completed.

ANS: A Once the cervix is completely dilated, the woman is able to use voluntary muscles to push. REF: Pages 814, 818 TOP: Second stage of labor

4. The pelvis is divided into two parts, the false and true pelvis. The nurse explains that the size of the true pelvis is most important because: a. the fetal head must pass through this part. b. these are the mother's measurements. c. the false pelvis can change. d. it needs to be larger.

ANS: A The size of the true pelvis is more important because the fetal head must be able to pass through. REF: Page 807 TOP: True pelvis

1. A woman who is 38 weeks pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. The nurse recognizes this as: a. lightening. b. Braxton-Hicks contractions. c. initiation of labor. d. engagement.

ANS: A The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally. REF: Page 805 TOP: Lightening

13. When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats per minute at the beginning of a contraction and returns to a baseline of 155 beats per minute at the end of the contraction. This indicates: a. early deceleration due to head compression. b. that the fetus is in acute distress. c. variable decelerations due to cord compression. d. that these are late decelerations.

ANS: A This indicates early decelerations due to head compression. REF: Page 825, Figure 26-18 TOP: Fetal monitoring

32. When the nurse performs the Nitrazine test on vaginal secretions of a primigravida who thinks her membranes have ruptured, the paper turns yellow. The nurse assesses this finding to indicate: a. acidic discharge, membranes intact. b. acidic discharge, membranes have ruptured. c. neutral, not enough discharge to measure. d. alkaline, membranes have ruptured.

ANS: A When the Nitrazine paper turns yellow it is indicative of acidic discharge. Amniotic fluid is alkaline and turns the paper blue. REF: Page 805, Box 26-1 TOP: Nitrazine test

14. The first-time mother has been told by the nurse that the first stage of labor is the longest. An appropriate nursing intervention for comfort during this time would be: a. cool fluids to drink. b. a backrub in the sacral area. c. assisting to lie in a supine position. d. decreasing illumination in the room.

ANS: B Backache in the sacral area is a common complaint during the first stage of labor. REF: Page 818 TOP: First stage of labor

23. During labor, the patient screams at her husband to get out of her sight. The nurse's most appropriate action would be to: a. encourage the husband to stay. b. assure the husband that such behavior is normal. c. remind the patient that the husband wants to help. d. change the patient's position.

ANS: B During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal. REF: Page 830 TOP: Care during labor

20. The nurse is assessing the printout from the fetal monitor. The nurse is legally responsible for: a. recognizing deviations and taking appropriate action to prevent harm to the fetus. b. recognizing deviations and notifying the physician. c. recognizing and documenting deviations. d. providing technical assessment.

ANS: B Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. REF: Page 826 TOP: Fetal monitoring

19. The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. The immediate action the nurse should take is: a. to monitor intensity of contractions. b. place the patient in the knee-chest position. c. notify the charge nurse. d. ask the patient to perform a Valsalva maneuver.

ANS: B The knee-chest position reduces the pressure on the cord with the pull of gravity. REF: Page 811 TOP: Cord prolapse

7. The nurse points out the largest diameter of the fetal skull is the: a. transverse. b. biparietal. c. lateral. d. frontal-occipital.

ANS: B The largest transverse diameter of the fetal skull is the biparietal measurement. REF: Page 808 TOP: Passageway

33. Which assessment findings suggest probable fetal distress? (Select all that apply.) a. Fetal heart rate (FHR) of 120 b. Meconium-stained amniotic fluid c. Decreased FHR during contractions d. Strong contractions 10 seconds apart e. Slow return of FHR to baseline

ANS: B, E Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are indicative of fetal distress. All other options are normal. REF: Page 826 TOP: Fetal distress

2. Braxton-Hicks contractions, which may begin in the first trimester and become increasingly stronger during the pregnancy, differ from labor contractions in that they: a. last several minutes. b. are always regular. c. do not dilate the cervix. d. are only mild.

ANS: C Braxton-Hicks contractions do not dilate the cervix. REF: Page 806 TOP: Braxton-Hicks contractions

3. The nurse differentiates false from true labor by explaining that in true labor: a. discomfort of the contraction is in the fundus. b. contractions do not follow a pattern. c. contractions get stronger with ambulation. d. contractions may stop with ambulation.

ANS: C Contractions get stronger with ambulation in true labor. REF: Page 806 TOP: True labor

31. Following delivery, the nurse must assess the mother to identify physiological changes during this stage. For the first hour, this assessment is done every: a. 5 minutes. b. 10 minutes. c. 15 minutes. d. 30 minutes.

ANS: C During the first hour, assessments are done every 15 minutes. REF: Page 819 TOP: Postdelivery assessment

24. A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. The nurse recognizes this means that the: a. narrowest diameter of the presenting part has reached the pelvic outlet. b. descending part is being initiated through the midpelvis. c. widest diameter of the presenting part has reached the pelvic outlet. d. narrowest diameter of the presenting part is at the ischial spines.

ANS: C Engagement occurs when the biparietal diameter of the fetal head reaches the pelvic outlet. REF: Page 816 TOP: Engagement

15. When monitoring the fetal heart rate (FHR), the nurse recognizes indications that the FHR is nonreassuring. This indicates to the nurse that the fetus is experiencing fetal distress most likely related to: a. birth trauma. b. strong contractions. c. hypoxia. d. aspiration.

ANS: C Fetal distress resulting from hypoxia is indicated by a nonreassuring FHR. REF: Page 826 TOP: Fetal distress

5. The nurse reassures the patient that the method used to determine the size of the true pelvis for over 20 years with no detrimental effects to the fetus is: a. pelvimetry. b. palpation. c. ultrasonography. d. x-ray.

ANS: C In more than 20 years of use, ultrasonography has had no detrimental effects on the fetus. REF: Page 808 TOP: Ultrasound

18. A patient arrives at the hospital and is not sure if she is in true labor. The nurse does an assessment and assures her she is in true labor because: a. there is no dilatation. b. the contractions are in the fundus. c. the cervix has softened and effaced. d. the contractions are irregular.

ANS: C One sign of true labor is when the cervix has softened and effaced. REF: Page 806 TOP: Effacement

28. After the delivery of the baby, the placenta is delivered in the third stage of labor. Oxytocin is administered. The nurse explains that the purpose of the drug is to: a. stimulate lactation. b. relieve postpartum pain. c. stimulate uterine contractions. d. sedate the mother so she can rest.

ANS: C Oxytocin makes the uterus contract to reduce postpartum hemorrhage. REF: Pages 819, 837 TOP: Third stage of labor

30. The physical condition of the infant is assessed at birth through the use of an Apgar score. If the infant has a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs 5 minutes after delivery, the baby's Apgar score is: a. 5. b. 7. c. 8. d. 10.

ANS: C The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2; pink body, blue limbs = 1 REF: Page 827, Table 26-5 TOP: Apgar scoring

17. The patient's membranes have just ruptured. The nurse is with her and knows that the first thing that must be done is to: a. turn the patient on the left side. b. perform a Nitrazine test. c. check the fetal heart rate (FHR). d. perform a vaginal examination.

ANS: C The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby. REF: Page 819 TOP: Ruptured membranes

21. A mother is in early labor and asks the nurse how long this will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until the: a. cervix is completely effaced. b. baby is in position. c. cervix is fully dilated. d. woman begins pushing.

ANS: C The first stage of labor begins with regular contractions and ends with complete dilatation of the cervix. REF: Page 818 TOP: Labor and delivery

9. The relationship of fetal body parts to one another during labor is called fetal attitude. The nurse explains that the ideal attitude for the fetal body is: a. extension. b. lateral. c. flexion. d. transverse.

ANS: C The ideal attitude for the fetal body is flexion. REF: Page 809 TOP: Attitude

16. A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 beats per minute. Based on that assessment, the nurse should: a. position patient on her left side. b. start oxygen per nasal cannula. c. reassure the mother the rate is normal. d. notify the physician at once.

ANS: C The normal FHR is 120 to 160 beats per minute. REF: Page 819 TOP: Fetal heart rate (FHR)

8. The nurse teaches a group of primigravidas that during delivery, pressure on the fetal skull may produce changes in the shape of the skull called: a. pressure response. b. overlapping. c. molding. d. spacing.

ANS: C The reshaping of the skull bones in response to pressure is called molding. REF: Page 808 TOP: Molding

26. A mother has entered the second stage of labor. The nurse states that this stage begins with complete dilatation of the cervix and ends: a. when the mother begins to push. b. when the baby's head crowns. c. with delivery of the baby. d. with delivery of the placenta.

ANS: C The second stage of labor begins with complete dilatation and ends with the birth of the baby. REF: Page 818 TOP: Second stage of labor

6. The nurse plans to use a picture to show the area of the uterus that provides the force during a contraction, which is the: a. lower portion. b. middle portion. c. upper portion. d. cervical portion.

ANS: C The upper portion of the uterus provides the force during contractions. REF: Page 808 TOP: Passageway Step: Planning

22. The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment, it is most important to assess: a. food and drug allergies. b. when the baby is due. c. when the patient last ate. d. the timing of contractions.

ANS: D Assessment begins with timing the contractions on admission to form a database. REF: Page 835, Box 26-5 TOP: Admission of labor patient

12. The nurse clarifies that the type of monitor that will assess the intensity of the contractions is a(n): a. external monitor. b. fetal monitor. c. maternal monitor. d. internal monitor.

ANS: D Internal monitoring is used to monitor intensity of contractions. REF: Page 823 TOP: Fetal monitoring

29. After the delivery of a newborn, the nurse's first action to meet the priority need of the newborn is to: a. place the newborn on the right side. b. cover the cord stump. c. dry the infant immediately. d. suction nose and mouth.

ANS: D To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent hypothermia. REF: Page 806 TOP: Newborn care