Chapter 11

In the second stage of labor, the nurse should plan to discourage a client from holding her breath longer than 7 seconds while pushing with each contraction. What complication does this prevent? A. Fetal hypoxia B. Perineal lacerations C. Carpopedal spasms D. Maternal hypertension

A.

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. How should the nurse respond? A. Have her pant-blow during contractions. B. Place her legs in stirrups to facilitate pushing. C. Encourage bearing down with each contraction. D. Review the pushing techniques taught in childbirth classes.

A.

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What description of amniotic fluid supports this conclusion? A. Clear, dark amber, and contains shreds of mucus B. Straw colored, clear, and contains little white specks C. Milky, greenish yellow, and contains shreds of mucus D. Greenish yellow, cloudy, and contains little white specks

B.

A primipara gave birth to an infant weighing 9 pounds 15 ounces. She had a mid-line episiotomy and a third-degree laceration. She tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain? A. Perineal muscles have been cut. B. The anal sphincter muscle has been injured. C. The anterior wall of the rectum is traumatized. D. Structures superficial to muscles have been damaged.

B.

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions? A. Relax by closing her eyes. B. Push with her glottis open. C. Blow to slow the birth process. D. Pant to prevent cervical edema.

B.

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious during this period and ask a nurse, "Do you think it is best for me to leave, because I don't seem to be doing my wife much good?" What is the nurse's BEST response? A. "This is the time your wife needs you. Don't run out on her now." B. "This is hard for you. Let me try to help you coach her during this difficult phase." C. I know this is hard for you. You should go have a cup of coffee to help you relax and then come back in a little while."

B.

Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor? A. The mechanical and chemical digestive processes require energy that is needed for labor. B. Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia. C. The gastric phase of digestion stimulates the release of hydrochloric acid and may cause dyspepsia. D. Food and fluid will further aggravate gastric peristalsis, which is already increased because of the stress of labor.

B.

Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse identifies that the fetus is experiencing late deceleration. List the following nursing actions in order of priority. A. Increase IV fluids B. Re-position client on her side C. Reassess fetal heart rate pattern D. If late deceleration persist, notify the health care provider E. Document interventions with related maternal/fetal responses

B. Re-position client on her side A. Increase IV fluids C. Reassess fetal heart rate pattern D. If late deceleration persist, notify the health care provider E. Document interventions with related maternal/fetal responses

A nurse performs Leopold maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in pubic area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify? A. Left sacroposterior (LPS) B. Right sacroposterior (RPS) C. Left occipitoanterior (LOA) D. Right occipitoanterior (ROA)

C.

A pregnant woman at 39 weeks' gestation arrives in the triage area of the birthing unit, stating she thinks her "water broke." What should the nurse do first? A. Auscultate the fetal heart to determine fetal well-being B. Perform Leopold maneuvers to rule out a breech presentations. C. Check the vaginal introitus for the presence of the umbilical cord. D. Do a nitrazine test on the vaginal fluid for verification of ruptured membranes.

C.

A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examinations reveals the cervix at 3 cm dilation and 75% effacement, +1 station with occiput anterior, and intact membranes. The client is cheerful and relaxed and ask the nurse whether it is all right for her to walk around. Based on observations of the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond? A. "I can't make a decision on that; I will have to ask your health care provider" B. "Please stay in bed; walking may interfere with the effective uterine contractions." C. "It's all right for you to walk as long as you feel comfortable and your membranes are intact." D. "You may sit in a chair because your contractions cannot be timed when you walk, and I won't be able to listen the fetal heath."

C.

After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled? A. Relaxation of the uterus. B. Descent of the uterus in the abdomen. C. Appearance of a sudden gush of blood. D. Retraction of the umbilical cord into the vagina.

C.

At 40 weeks' gestation a client is admitted to the birthing unit in early labor. She ask the nurse, "Why do you want me to lie on my side?" What response explains the primary purpose of the side-lying position during labor? A. "Lying on the side prevents fetal hyperactivity." B. It decreases the incidence of nausea and vomiting." C. "It enhances blood flow to the uterus and contractions." D. "Lying on the side encourages descent of the presenting part."

C.

During a client's labor, the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's first intervention? A. Insert a urinary retention catheter. B. Administer oxygen via nasal cannula. C. Assist the client to turn to the side lying position. D. Encourage the client to pant with her next contractions.

C.

The membranes of a client who is at 39 weeks' gestation have ruptured spontaneously. Examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaced, and the FHR is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival? A. Place the client in bed and attach an external fetal monitor. B. Have the client undress while taking her history from her partner. C. Introduce the staff nurses to the couple and try to make them feel welcome. D. Ask the couple to wait in the examining room while notifying the health care provider.

C.

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What should the nurse tell the client to do? A. Pant while pushing gently. B. Breathe with her mouth closed. C. Hold her breath while bearing down. D. Pant while resisting the urge to bear down.

D.

When a client's legs are placed in stirrups for birth, the nurse confirms that both legs are positioned simultaneously to prevent what? A. Venous stasis in the legs B. Pressure on the perineum C. Excessive pull on the fascia D. Trauma to the uterine ligaments

D.