Chapter 6 - Nursing Care of Mother and Infant During Labor and Birth

After the membranes have ruptured, the nurse should assess the fetal heart rate (FHR) for ________ minute(s).

Answer: 1 Rationale: The FHR is checked for 1 full minute to ensure that the infant is not in distress from cord compression resultant from the lost buoyancy.

What do late decelerations indicate? (Select all that apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression

Answer: A, B, C Rationale: This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord compression and early decelerations indicate head compressions.

What are the advantages of a freestanding birth center? (Select all that apply.) a. Home-like setting. b. Designed for high-risk pregnancies. c. Lower costs. d. Attended by certified obstetricians. e. Immediate emergency access.

Answer: A, C Rationale: Advantages of a freestanding birth center include a homelike setting and lower costs because the center does not require expensive departments such as emergency or critical care. Freestanding birth centers are not designed for high-risk patients, are not attended by certified obstetricians, and do not have immediate emergency access.

While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions? (Select all that apply.) a. Provide for extreme modesty. b. Assign a male caregiver. c. Arrange for the husband/partner to participate in labor. d. Provide adequate pain control. e. Respect protective amulets.

Answer: A, D, E Rationale: Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and religious amulets. The husband is in attendance but not as a participant. Arabs prefer female caregivers. If a male is in attendance, then the husband will remain in the room as long as the male is there.

Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor. Place the seven mechanisms of labor in sequential order. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Extension b. Engagement c. Descent d. Flexion e. Expulsion f. Internal rotation g. External rotation

Answer: C, B, D, F, A, G, E Rationale: The process by which a normal vaginal delivery is accomplished requires the infant to make the descent into the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled.

A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After a thorough examination and diagnostic testing, it is determined to be false (prodromal) labor. What signs and symptoms would lead the nurse to suspect false (prodromal) labor? (Select all that apply.) a. Leaking of vaginal fluid. b. Contractions intensify with ambulation. c. Pink spotting. d. Painless tightening of abdominal muscles. e. Cervix thick and not effaced.

Answer: D, E Rationale: Painless tightening of abdominal muscles (Braxton-Hicks contractions) and cervix thick and not effaced lend to the determination of false (prodromal) labor. Leaking of vaginal fluid may indicate rupture of membranes and is a sign of true labor. Contractions that intensify with ambulation and pink spotting (bloody show) are signs of true labor.

The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called _____________________________ _____________________________.

Answer: Leopolds maneuver Rationale: The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called Leopolds maneuver.

One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action? a. Check the fundus for position and firmness. b. Report to the doctor immediately. c. Change the pads and chart the time. d. Time how long it takes to soak one pad.

Answer: a. Check the fundus for position and firmness. Rationale: Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

The physician performs an amniotomy on a laboring woman. What will be the nurses priority assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes

Answer: a. Fetal heart rate. Rationale: The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.

The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warm fluids to drink. b. By helping the patient to ambulate in the room. c. By seating the patient upright in a straight-back chair. d. By positioning the patient on her right side.

Answer: b. By helping the patient to ambulate in the room. Rationale: Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.

What marks the end of the third stage of labor? a. Full cervical dilation. b. Expulsion of the placenta and membranes. c. Birth of the infant. d. Engagement of the head.

Answer: b. Expulsion of the placenta and membranes. Rationale: The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.

The nurse observes the patient bearing down with contractions and crying out, The baby is coming! What is the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the womans partner to locate a registered nurse. d. Assist with deep breathing to slow the labor process.

Answer: b. Stay with the woman and use the call bell to get help. Rationale: If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

A nursing student is observing prenatal exams in the office setting. The health care provider informs the student that the fetal position is LSA. The student interprets this as a ____________________ presentation.

Answer: breech Rationale: LSA is the abbreviation for Left Sacrum Anterior. This is a breech presentation.

What is the most important nursing intervention during the fourth stage of labor? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding.

Answer: c. Assess for hemorrhage. Rationale: Immediately after giving birth, every woman is assessed for signs of hemorrhage.

What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine. b. Decrease flow of intravenous (IV) fluids. c. Increase oxygen to 10 L/minute. d. Prepare to increase oxytocin drip.

Answer: c. Increase oxygen to 10 L/minute. Rationale: The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.

What is the function of contractions during the second stage of labor? a. Align the infant into the proper position for delivery. b. Dilate and efface the cervix. c. Push the infant out of the mothers body. d. Separate the placenta from the uterine wall.

Answer: c. Push the infant out of the mothers body. Rationale: The contractions push the infant out of the mothers body as the second stage of labor ends with the birth of the infant.

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurses initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula.

Answer: c. Reposition the woman on her side. Rationale: Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

What is the nurse primarily concerned about maintaining in the initial care of the newborn? a. Fluid intake. b. Feeding schedule. c. Thermoregulation. d. Parental bonding.

Answer: c. Thermoregulation. Rationale: Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.

The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this stage of labor? a. They get the infant positioned for delivery. b. They push the infant into the vagina. c. They dilate and efface the cervix. d. They get the mother prepared for true labor.

Answer: c. They dilate and efface the cervix. Rationale: The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows that what indicates the beginning of true labor? a. Contractions that are relieved by walking. b. Discomfort in the abdomen and groin. c. A decrease in vaginal discharge. d. Regular contractions becoming more frequent and intense.

Answer: d. Regular contractions becoming more frequent and intense. Rationale: In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fear related to the probable need for cesarean delivery. c. Dysuria related to prolonged labor and decreased intake. d. Risk for injury related to hemorrhage.

Answer: d. Risk for injury related to hemorrhage. Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.

At 1 and 5 minutes of life, a newborns Apgar score is 9. What does the nurse understand that a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in stable condition.

Answer: d. The newborn is in stable condition. Rationale: Apgar scoring is a system for evaluating the infants need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is stable.

A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth? a. Eclampsia. b. Placental abruption. c. Congestive heart failure. d. Uterine rupture.

Answer: d. Uterine rupture. Rationale: Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous cesarean birth.

The nurse explains that the four Ps of the birth process are __________, __________, __________, and __________.

Answer: powers, passenger, passage, psyche Rationale: The four interrelated components of the process of labor and birth, called the four Ps, are powers, passenger, passage, and psyche.

After the pregnant woman is admitted to the labor suite, the nurse assesses the position of the infant as ROA; this means that the infants head is _________ __________ _________.

Answer: right occiput anterior Rationale: Right occiput anterior means that the infants right occiput is toward the anterior aspect of the mothers body.