Chapter 16: Nursing Care of the Family during Labor and Birth

If a woman complains of back labor pain, the nurse could best suggest that she: a. Lie on her back for a while with her knees bent. b. Do less walking around. c. Take some deep, cleansing breaths. d. Lean over a birth ball with her knees on the floor.

d. Lean over a birth ball with her knees on the floor.

Women who have participated in childbirth education classes often bring a "birth bag" or "Lamaze bag" with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including (Select all that apply): a. Rolling pin. b. Tennis balls. c. Pillow. d. Stuffed animal or photo. e. Candles.

A, B, C, D

The nurse recognizes that a woman is in true labor when she states: a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

c. "The contractions in my uterus are getting stronger and closer together."

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant? a. 7 b. 8 c. 9 d. 10

c. 9

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: a. Subside when I walk around." b. Cause discomfort over the top of my uterus." c. Continue and get stronger even if I relax and take a shower." d. Remain irregular but become stronger."

c. Continue and get stronger even if I relax and take a shower."

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture

b. When accelerations of the fetal heart rate (FHR) are noted

A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to: a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine whether fetal tachycardia is present.

a. Ask her to turn to one side.

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: a. Dilation of the cervix. b.Descent of the fetus. c. Rupture of the amniotic membranes. d. Increase in bloody show.

a. Dilation of the cervix.

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: a. Encouraging the woman to try various upright positions, including squatting and standing. b. Telling the woman to start pushing as soon as her cervix is fully dilated. c. Continuing an epidural anesthetic so pain is reduced and the woman can relax. d. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

a. Encouraging the woman to try various upright positions, including squatting and standing.

Leopold maneuvers would be an inappropriate method of assessment to determine: a. Gender of the fetus. b. Number of fetuses. c. Fetal lie and attitude. d. Degree of the presenting part's descent into the pelvis.

a. Gender of the fetus.

What is an essential part of nursing care for the laboring woman? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Sharing personal experiences regarding labor and delivery to decrease her anxiety d. Feeling comfortable with the predictable nature of intrapartum care

a. Helping the woman manage the pain

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: a. Increase with activity such as ambulation. b. Decrease with activity. c. Are always accompanied by the rupture of the bag of waters. d. Alternate between a regular and an irregular pattern.

a. Increase with activity such as ambulation.

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _________________________ has increased. a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension

a. Intrauterine infection

The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the newborn's airway clear. b. Fostering parent-newborn attachment. c. Drying the newborn and wrapping the infant in a blanket. d. Administering eye drops and vitamin K.

a. Keeping the newborn's airway clear.

As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance? a. Mexico c. Iran b. China d. India

a. Mexico

A means of controlling the birth of the fetal head with a vertex presentation is: a. The Ritgen maneuver. c. The lithotomy position. b. Fundal pressure. d. The De Lee apparatus.

a. The Ritgen maneuver.

When assessing a multiparous woman who has just given birth to an 8-pound 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: a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segment.

a. The placenta has separated.

The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. Relieve pain. b.Stimulate uterine contraction. c.Prevent infection. d. Facilitate rest and relaxation.

b.Stimulate uterine contraction.

With regard to a woman's intake and output during labor, nurses should be aware that: a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly.

a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: a. "Don't worry about it. You'll do fine." b. "It's normal to be anxious about labor. Let's discuss what makes you afraid." c. "Labor is scary to think about, but the actual experience isn't." d. "You can have an epidural. You won't feel anything."

b. "It's normal to be anxious about labor. Let's discuss what makes you afraid."

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage

b. Active phase

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours

b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours

Concerning the third stage of labor, nurses should be aware that: a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.

b. An expectant or active approach to managing this stage of labor reduces the risk of complications.

A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are: a. Contraction pattern, amount of discomfort, and pregnancy history. b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. Identification of ruptured membranes, the woman's gravida and para, and her support person. d. Last food intake, when labor began, and cultural practices the couple desires.

b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth.

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: a. First stage, latent phase. b. First stage, active phase. c. First stage, transition phase. d. Second stage, latent phase.

b. First stage, active phase.

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care? a. Telling the client to relax and that it won't hurt much b. Limiting the number of procedures that invade her body c. Reassuring the client that as the nurse you know what is best d. Allowing unlimited care providers to be with the client

b. Limiting the number of procedures that invade her body

What is an expected characteristic of amniotic fluid? a. Deep yellow color b. Pale, straw color with small white particles c. Acidic result on a Nitrazine test d. Absence of ferning

b. Pale, straw color with small white particles

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to: a. Facilitate maternal-newborn interaction. b. Stimulate the uterus to contract. c. Prevent neonatal hypoglycemia. d. Initiate the lactation cycle.

b. Stimulate the uterus to contract.

Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when: a. The woman has a sudden episode of vomiting. b. The nurse is unable to feel the cervix during a vaginal examination. c. Bloody show increases. d. The woman involuntarily bears down.

b. The nurse is unable to feel the cervix during a vaginal examination.

The primary difference between the labor of a nullipara and that of a multipara is the: a. Amount of cervical dilation. b. Total duration of labor. c. Level of pain experienced. d. Sequence of labor mechanisms.

b. Total duration of labor.

Which description of the phases of the second stage of labor is accurate? a. Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied d. Transitional phase: Woman "laboring down," fetal station 0, duration 15 minutes

c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips. b. Determine the frequency by timing from the end of one contraction to the end of the next contraction. c. Evaluate the intensity by pressing the fingertips into the uterine fundus. d. Assess uterine contractions every 30 minutes throughout the first stage of labor.

c. Evaluate the intensity by pressing the fingertips into the uterine fundus.

A nulliparous woman who has just begun the second stage of her labor would most likely: a. Experience a strong urge to bear down. b. Show perineal bulging. c. Feel tired yet relieved that the worst is over. d. Show an increase in bright red bloody show.

c. Feel tired yet relieved that the worst is over.

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is: a. Usually directly over the fetal abdomen. b. In a vertex position heard above the mother's umbilicus. c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally. d. In a breech position heard below the mother's umbilicus. ANS: C

c. Heard lower and closer to the midline of the mother's abdomen as the fetus descends and rotates internally.

The nurse thoroughly dries the infant immediately after birth primarily to: a. Stimulate crying and lung expansion. b. Remove maternal blood from the skin surface. c. Reduce heat loss from evaporation. d. Increase blood supply to the hands and feet.

c. Reduce heat loss from evaporation.

It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care? a. The patient is not considered to be in true labor (according to the Emergency Medical Treatment and Active Labor Act [EMTALA]) until a qualified health care provider says she is. b. The woman can have only her male partner or predesignated "doula" with her at assessment. c. The patient's weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth. d. The nurse may exchange information about the patient with family members.

c. The patient's weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth.

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

c. The vulva bulges and encircles the fetal head.

The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture. b. The cervix cannot be felt during a vaginal examination. c. The woman experiences a strong urge to bear down. d. The presenting part is below the ischial spines.

c. The woman experiences a strong urge to bear down.

In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except: a. Frequency (how often contractions occur). b. Intensity (the strength of the contraction at its peak). c. Resting tone (the tension in the uterine muscle). d. Appearance (shape and height).

d. Appearance (shape and height).

Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)? a. A dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. A reddish-haired mother of two who is going through a breech birth c. A dark-skinned, first-time mother who is going through a long labor d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician

d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician

When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should: a. Tell the woman to stay home until her membranes rupture. b. Emphasize that food and fluid intake should stop. c. Arrange for the woman to come to the hospital for labor evaluation. d. Ask the woman to describe why she believes she is in labor.

d. Ask the woman to describe why she believes she is in labor.

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate and pattern.

d. Assess the fetal heart rate and pattern.

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. Admitted and prepared for a cesarean birth. b. Admitted for extended observation. c. Discharged home with a sedative. d. Discharged home to await the onset of true labor.

d. Discharged home to await the onset of true labor.

The nurse who performs vaginal examinations to assess a woman's progress in labor should: a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner.

d. Discuss the findings with the woman and her partner.

For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of: a. The onset of progressive, regular contractions. b. The bloody, or pink, show. c. The spontaneous rupture of membranes. d. Formulation of the woman's plan of care for labor.

d. Formulation of the woman's plan of care for labor.