Chapter 06: Nursing Care of Mother and Infant During Labor and Birth

15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of: a. a well-oxygenated fetus. b. compression of the umbilical cord. c. compression of the fetal head. d. uteroplacental insufficiency.

ANS: A Accelerations in the fetal heart rate suggest that the fetus is well oxygenated. DIF: Cognitive Level: Analysis REF: p. 134 OBJ: 7 TOP: Fetal Accelerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. To relieve perineal bruising and edema following delivery the nurse should: a. place an ice pack on the area for 12 hours. b. place a warm pack on the perineal area for 24 hours. c. administer aspirin to relieve inflammation. d. change the perineal pad frequently.

ANS: A An ice pack can be placed on the mother's perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours following delivery. DIF: Cognitive Level: Comprehension REF: p. 150 OBJ: 7 TOP: Ice Pack/Bruising KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates: a. fetal distress. b. fetal maturity. c. intact gastrointestinal tract. d. dehydration in the mother.

ANS: A Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise. DIF: Cognitive Level: Analysis REF: p. 137 OBJ: 7 TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, the nurse assesses the most likely explanation for the woman's change in behavior is that: a. labor has progressed to the transition phase. b. she lacked adequate preparation for the labor experience. c. the woman would benefit from a different form of analgesia. d. the contractions have increased from mild to moderate intensity.

ANS: A If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor. DIF: Cognitive Level: Analysis REF: p. 145, Table 6-6 OBJ: 6 TOP: Transition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. This presentation is referred to as: a. vertex. b. military. c. brow. d. face.

ANS: A In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest. DIF: Cognitive Level: Application REF: p. 124 OBJ: 7 TOP: Fetal Position KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. The nurse should: 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.

ANS: A Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery. DIF: Cognitive Level: Application REF: p. 147 OBJ: 7 TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

22. The husband of a woman in labor asks, "What does it mean when the baby is at minus 1 station?" After giving an explanation, the nurse determines that teaching was effective when the husband states the fetal head is: a. above the ischial spines. b. below the ischial spines. c. engaged in the mother's pelvis. d. visible at the perineum.

ANS: A Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines. Minus stations are above the ischial spines. DIF: Cognitive Level: Application REF: p. 127, Figure 6-10 OBJ: 1 TOP: Mechanisms of Labor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. 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

ANS: A, B, C This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord compression and early decelerations indicate head compressions. DIF: Cognitive Level: Application REF: p. 136 OBJ: 7 TOP: Late Decelerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

28. What are the advantages of a free-standing 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

ANS: A, C DIF: Cognitive Level: Application REF: p. 116 OBJ: 3 TOP: Free-Standing Birth Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE 27. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which intervention(s)? 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.

ANS: A, D, E 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. DIF: Cognitive Level: Analysis REF: p. 117, Table 6-1 OBJ: 2 TOP: Cultural Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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

ANS: B Ambulation will stimulate effacement and intensify contractions if the patient is in true labor. DIF: Cognitive Level: Comprehension REF: p. 131 OBJ: 5 TOP: Differentiating Between True and False Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. When the nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" The nurse should: a. go find the physician. b. stay with the woman and use the call bell to get help. c. send the woman's partner to locate a registered nurse. d. assist with deep breathing to slow the labor process.

ANS: B If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell. DIF: Cognitive Level: Application REF: p. 129 OBJ: 6 TOP: Imminent Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The nurse explains that the third stage of labor ends with: a. full cervical dilation. b. expulsion of the placenta and membranes. c. birth of the infant. d. engagement of the head.

ANS: B The third stage of labor extends from the birth of the infant until the placenta is detached and expelled. DIF: Cognitive Level: Knowledge REF: p. 146, Table 6-6 OBJ: 6 TOP: Third Stage of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. The nurse would record this presentation as: a. complete breech. b. frank breech. c. double footling. d. buttocks presentation.

ANS: B When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders. DIF: Cognitive Level: Application REF: p. 124, Figure 6-7 OBJ: 7 TOP: Components of the Birth Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. The relaxation phase between contractions is important because the: a. laboring woman needs to rest. b. uterine muscles fatigue without relaxation. c. contractions can interfere with fetal oxygenation. d. infant progresses toward delivery at these times.

ANS: C Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus. DIF: Cognitive Level: Comprehension REF: p. 121 OBJ: 6 TOP: Interval KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The most important nursing activity during the fourth stage of labor is to: a. monitor the frequency and intensity of contractions. b. provide comfort measures. c. assess for hemorrhage. d. promote bonding.

ANS: C Immediately after giving birth, every woman is assessed for signs of hemorrhage. DIF: Cognitive Level: Comprehension REF: p. 147 OBJ: 7 TOP: Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

3. The nurse recognizes the contraction duration and interval that could result in fetal compromise is: a. duration shorter than 30 seconds, interval longer than 75 seconds. b. duration shorter than 90 seconds, interval longer than 120 seconds. c. duration longer than 90 seconds, interval shorter than 60 seconds. d. duration longer than 60 seconds, interval shorter than 90 seconds.

ANS: C Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply. DIF: Cognitive Level: Analysis REF: p. 121, Safety Alert OBJ: 7 TOP: Contraction/Fetal Compromise KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk

19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurse's initial action is to: a. stop the oxytocin infusion. b. increase the intravenous flow rate. c. reposition the woman to her side. d. start oxygen via nasal cannula.

ANS: C 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. DIF: Cognitive Level: Analysis REF: p. 139 OBJ: 7 TOP: Variable decelerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. The nurse's most informative response would be that the woman should come when she: a. feels increased fetal movement. b. has contractions that are 10 minutes apart. c. thinks her membranes have ruptured. d. has abdominal or groin discomfort.

ANS: C Ruptured membranes are an indication that the woman should go to the hospital or birthing center. DIF: Cognitive Level: Application REF: p. 127 OBJ: 6 TOP: Admission to the Hospital or Birth Center KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. The nurse explains that the function of contractions during the second stage of labor is to: a. align the infant into the proper position for delivery. b. dilate and efface the cervix. c. push the infant out of the mother's body. d. separate the placenta from the uterine wall.

ANS: C The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant. DIF: Cognitive Level: Knowledge REF: p. 145, Table 6-6 OBJ: 6 TOP: Second Stage of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse caring for a woman in the first stage of labor reminds the patient that contractions during this stage of labor: a. get the infant positioned for delivery. b. push the infant into the vagina. c. dilate and efface the cervix. d. get the mother prepared for true labor.

ANS: C The first stage of labor describes the time from the onset of labor until full dilation of the cervix. DIF: Cognitive Level: Comprehension REF: p. 145, Table 6-6 OBJ: 6 TOP: First Stage of Labor KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. When late decelerations occur, the nurse should: 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.

ANS: C 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. DIF: Cognitive Level: Application REF: p. 137 OBJ: 7 TOP: Late Decelerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

26. The nurse takes into consideration that the primary concern in the initial care of the newborn is maintaining: a. fluid intake. b. feeding schedule. c. thermoregulation. d. parental bonding.

ANS: C Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia. DIF: Cognitive Level: Knowledge REF: p. 150 OBJ: 7 TOP: Thermoregulation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

13. During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may: a. interfere with cervical dilation. b. obstruct progress of the infant through the birth canal. c. obstruct the passage of the placenta. d. predispose the mother to uterine hemorrhage.

ANS: D A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions. DIF: Cognitive Level: Application REF: p. 146, Table 6-6 OBJ: 6 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

21. At 1 and 5 minutes of life, a newborn's Apgar score is 9. The nurse understands that a score of 9 indicates this newborn: a. will require resuscitation. b. may have physical disabilities. c. will have above average intelligence. d. is in stable condition.

ANS: D Apgar scoring is a system for evaluating the infant's 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. DIF: Cognitive Level: Implementation REF: p. 151, Table 6-7 OBJ: 10 TOP: Care of the Infant After Birth KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is: 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.

ANS: D In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage. DIF: Cognitive Level: Application REF: p. 147 OBJ: 6 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by: 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.

ANS: D In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense. DIF: Cognitive Level: Application REF: p. 127 OBJ: 8 TOP: Initiation of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

1. The nurse measures the frequency of a laboring woman's contractions by noting: a. how long the patient states the contractions last. b. the time between the end of one contraction and the beginning of the next. c. the time between the beginning and the end of one contraction. d. the time between the beginning of one contraction and the beginning of the next.

ANS: D The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction. DIF: Cognitive Level: Comprehension REF: p. 120 OBJ: 7 TOP: Frequency of Contractions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The nurse would coach the laboring woman with a fully dilated cervix to push by saying: a. "At the beginning of a contraction, hold your breath and push for 10 seconds." b. "Take a deep breath and push between contractions." c. "Begin pushing when a contraction starts and continue for the duration of the contraction." d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation."

ANS: D When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, then take another deep breath and push while exhaling. DIF: Cognitive Level: Application REF: p. 142 OBJ: 7 TOP: Instructions for Pushing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation