MNB Chapt 6
16. The nurse would coach the laboring woman with a fully dilated cervix to push by saying:
"At the beginning of a contraction, take two deep breaths and push with the second exhalation." ANS: p.142 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. For about 4-6 sec at time. Prolonged breath holding can impair fetal blood circulation.
17. The most important nursing activity during the fourth stage of labor is to:
Assess for hemorrhage. ANS: p.147 Immediately after giving birth, every woman is assessed for signs of hemorrhage. +Nursing care 4 stage: Evaluating and intervening for pain. Observing bladder function and urine output. Evaluating recovery from anesthesia, Providing initial care to NB, and Promoting bonding.
18. One hour post delivery the nurse notes the new mother has saturated three perineal pads. The nurse should:
Check the fundus for position and firmness. ANS: p.147 and 241 Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. Massage the fundus until firm (control bleeding 1st), and then address emptying the bladder. One pad an hour is an acceptable rate for immediate post delivery.
9. The nurse caring for a woman in the first stage of labor reminds the patient that contractions during this stage of labor:
Dilate and efface the cervix. ANS: p.145 The first stage of labor describes the time from the onset of labor until full dilation of the cervix.
3. The nurse recognizes the contraction duration and interval that could result in fetal compromise is:
Duration longer than 90 seconds, interval shorter than 60 seconds. ANS: p. 121 Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.
12. The nurse explains that the third stage of labor ends with:
Expulsion of the placenta and membranes. ANS:p.145 The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.
5. When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates:
Fetal distress. ANS: p. 124 Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.
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:
Frank breech. ANS: p.124 When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.
25. When late decelerations occur, the nurse should:
Give oxygen 8-10 L/min by facemask. ANS: 137 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 then Patient is positioned to prevent supine hypotension. HCP are notified after any nonreassuring pattern after initial steps are taken to correct it.
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:
Helping the patient to ambulate in room. ANS: 131 Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
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:
Is in stable condition. ANS: p.151 Apgar scoring is a system for evaluating the infant's need for resuscitation at birth. Five categories are evaluated on a scale from 0(bad) to 2(good) with the highest score being 10. A score of 9 indicates that the newborn is stable.
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:
Labor has progressed to the transition phase ANS: p.145 If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.
20. To relieve perineal bruising and edema following delivery the nurse should:
Place an ice pack on the area for 12 hours. ANS: p.150 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.
13. During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may:
Predispose the mother to uterine hemorrhage. ANS: p.146 A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions
11. The nurse explains that the function of contractions during the second stage of labor is to:
Push the infant out of the mother's body. ANS: p.145 The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant.
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:
Regular contractions becoming more frequent and intense. ANS: p. 127 In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.
14. When the nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" The nurse should:
Stay with the woman and use the call bell to get help. ANS: p. 129 If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.
26. The nurse takes into consideration that the primary concern in the initial care of the newborn is maintaining:
Thermoregulation. ANS: 150 Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia
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:
Thinks her membranes have ruptured. ANS: p.127 Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
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 well-oxygenated fetus. ANS: p.134 Accelerations in the fetal heart rate suggest that the fetus is well oxygenated
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
a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression ANS: 136 This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord compression and early decelerations indicate head compressions.
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.
a. Provide for extreme modesty. 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.
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
a.Home-like setting b.Lower costs ANS: p. 116
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:
above the ischial spines. ANS: 127 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.
2. The relaxation phase between contractions is important because the:
contractions can interfere with fetal oxygenation. ANS: p. 121 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.
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:
reposition the woman to her side. ANS: p.139 Repositioning the woman is the first response to a pattern of variable decelerations.They are cause by umbilical cord compression. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.
23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is:
risk for injury related to hemorrhage. ANS: 147 In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
1. The nurse measures the frequency of a laboring woman's contractions by noting:
the time between the beginning of one contraction and the beginning of the next. ANS: p. 120 The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.
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:
vertex. ANS: p. 121 In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.