Chapter 16: Giving Birth
20. A woman at 40 weeks of gestation calls the OB triage nurse to report a trickle of fluid from her vagina. What action by the nurse is most appropriate? a. Instruct the woman to come to the hospital. b. Ask her to time her contractions. c. Tell her if she saturates two pads in an hour to come to the hospital. d. Reassure her that she has plenty of time before delivery.
ANS: A A trickle of fluid from the vagina may indicate rupture of the membranes requiring evaluation for infection or cord compression. Timing the contractions, waiting until she saturates two pads in an hour, and telling her there is plenty of time before she delivers are inappropriate actions and could lead to complications. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 305 | Patient-Centered Teaching Box OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
12. What assessment finding does the nurse expect in a woman with cervical dilation and effacement? a. Bloody show b. False labor c. Lightening d. Bladder distention
ANS: A As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries, leading to bloody show. Cervical dilation and effacement do not occur with false labor. Lightening is the descent of the fetus toward the pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied frequently. It may slow down the decent of the fetus during labor. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Table 16.2 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Engagement b. Extension c. Internal rotation d. External rotation
ANS: A Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 299 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
19. What nursing intervention is the priority when caring for a laboring woman? a. Helping the woman find ways to manage the pain b. Eliminating the pain associated with labor c. Sharing personal experiences regarding labor and delivery d. Providing the woman food to restore her energy
ANS: A Helping a woman manage the pain is an essential part of nursing care, because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. Sharing experiences can sometimes be appropriate, but managing the pain is the priority. Some women may want food during labor, and some may not, but this is not the priority. PTS: 1 DIF: Cognitive Level: Application REF: p. 288 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
16. Leopold's maneuvers are used by practitioners to determine a. the best location to assess the fetal heart rate (FHR). b. cervical dilation and effacement. c. whether the fetus is in the posterior position. d. if the woman needs an amniotomy.
ANS: A Leopold's maneuvers are often performed before assessing the FHR. These maneuvers help identify the best location to obtain the FHR. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination. Leopold's maneuvers are not used to determine if the woman needs an amniotomy. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 305 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
23. The nurse auscultates the fetal heart rate (FHR) and determines a rate of 152. Which nursing intervention is most appropriate? a. Document the findings in the chart. b. Reassess the FHR every 5 minutes. c. Report the FHR to the provider or nurse-midwife immediately. d. Apply oxygen and turn the mother on her left side.
ANS: A The FHR is within the expected range; no further action is necessary at this point other than documenting the findings in the chart. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 16.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
36. The registered nurse tells the nursing student that which stage of labor varies most in length? a. First b. Second c. Third d. Fourth
ANS: A The first stage is much longer than the second and third stages combined. In a first pregnancy, the first stage of labor can take up to 20 hours. However, there is great variability in length of time depending on many factors, including parity. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 302 | Table 16.1 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
29. A 25-year-old primigravida is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly the woman pushes her husband's hand away and shouts, "Don't touch me!" What action by the nurse is most appropriate? a. Reassure the husband this is normal in the transition phase. b. Ask the woman if she needs some pain medication. c. Call the anesthesia provider for an epidural block. d. Ask the husband to leave the room for a few minutes.
ANS: A The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. The woman may or may not need pain medication or an epidural, but the husband should be reassured. There is no need for the husband to be asked to leave. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 299 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
13. The nurse is caring for a woman whose fetus has a breech presentation. What complication does the nurse prepare to assist with? a. Umbilical cord compression b. More rapid labor c. A high risk of infection d. Maternal perineal trauma
ANS: A The umbilical cord can be compressed between the fetal body and the maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection or perineal trauma with a breech birth. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 295 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
24. A laboring woman is lying in the supine position. The most appropriate nursing action is to a. ask her to turn to one side. b. elevate her feet and legs. c. take her blood pressure. d. let her stay in a position of comfort.
ANS: A The woman's supine position may cause the heavy uterus to compress her inferior vena cava, reducing blood return to her heart and reducing placental blood flow. This problem is relieved by having her turn onto her side. The other actions will not prevent this from happening. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 315 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
34. The nurse notes that a woman who has given birth 1 hour ago is touching her infant with the fingertips and talking to him softly in high-pitched tones. On the basis of this observation, the nurse should a. document this evidence of normal early maternal-infant attachment behavior. b. observe for other signs that the mother may not be accepting of the infant. c. request a social service consult for psychosocial support. d. determine whether the mother is too fatigued to interact normally with her infant.
ANS: A These are signs of normal attachment behavior; no other assessment or intervention is necessary at this point. PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 329 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
2. A woman who is gravida 3 para 2 enters the intrapartum unit. Which nursing assessments take priority at this time? (Select all that apply.) a. Fetal heart rate b. Maternal vital signs c. The woman's nearness to birth d. Contraction patterns e. Last food and water intake
ANS: A, B, C
MULTIPLE RESPONSE 1. The nurse who elects to practice in the area of obstetrics learns about the "four Ps." What are the "four Ps"? a. Powers b. Passage c. Position d. Passenger e. Psyche
ANS: A, B, D, E Powers: the two powers of labor are uterine contractions and pushing efforts. During the first stage of labor through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. Passage: the passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor, because bones and joints do not yield as readily to the forces of labor. Passenger: this is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. Psyche: the psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman's ability to cope. Position is not one of the "four Ps." PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 291 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
15. Which maternal factor may inhibit fetal descent and require further nursing interventions? a. Decreased peristalsis b. A full bladder c. Reduction in internal uterine size d. Rupture of membranes
ANS: B A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Contractions will reduce the internal uterine size in order to assist fetal descent. Rupture of membranes will assist in the fetal descent. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 326 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
32. Thirty minutes after giving birth a woman's uterus feels boggy to the nurse. The nurse massages the fundus without change. What action does the nurse take next? a. Notify the provider or nurse-midwife immediately. b. Assess the woman for a full bladder. c. Prepare to administer oxytocin. d. Take a full set of vital signs.
ANS: B After massaging the uterus, without result, the nurse should assess the woman to see if a full bladder is contributing to the uterine atony. The woman can then be catheterized to empty the bladder. None of the other actions is needed. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 327 | Table 16.4 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
38. At hand-off report the off-going nurse states that the patient demonstrated clonus on her last assessment. What action by the on-coming nurse takes priority? a. Repeat the woman's vital signs. b. Institute seizure precautions. c. Prepare for cesarean delivery. d. Assess for pain.
ANS: B Clonus (repeated tapping when the foot is dorsiflexed) is usually associated with pregnancy-induced hypertension and may precede a seizure. The nurse should place the woman on seizure precautions. Vital signs should be assessed frequently, but this is not the priority. There is no need at this point for cesarean delivery, although that is possible. Assessing for pain is important but does not take priority over a safety measure. PTS: 1 DIF: Cognitive Level: Application/Applying REF: Table 16.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
6. To assess the duration of labor contractions, the nurse determines the time a. from the beginning of one contraction to the beginning of the next. b. from the beginning to the end of each contraction. c. of the strongest intensity of each contraction. d. of uterine relaxation between two contractions.
ANS: B Duration of labor contractions is the average length of contractions from beginning to end. Assessing from the beginning of one contraction to the beginning of the next is the frequency. The strongest intensity of each contraction is the strength or intensity. The interval of the contraction phase is the time of uterine relaxation between two contractions. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 314 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
2. A student nurse is trying to assess vital signs on a laboring woman. Which statement by the registered nurse is the best rationale for assessing maternal vital signs between contractions? a. During a contraction, assessing fetal heart rates is the priority. b. Maternal circulating blood volume increases temporarily during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate.
ANS: B During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows pulse. It is important to monitor fetal response to contractions, but the question is concerned with the maternal vital signs so assessing the fetal heart rate is not the priority. Vital signs are altered by contractions but are considered accurate for that period of time. However, they do not reflect the woman's baseline. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 289 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
26. During the active phase of labor, the FHR of a low-risk patient should be assessed every a. 10 to 15 minutes. b. 15 to 30 minutes. c. 30 to 45 minutes. d. 1 hour.
ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 15 to 30 minutes during the active phase of labor. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 310 | Table 16.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
14. 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.
ANS: B Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. Cervical dilation and the sequence of labor mechanisms is the same for all labors. Level of pain is individual to the woman, not to the number of labors she has experienced. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: Table 16.1 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
11. To teach and support the woman in labor, the nurse explains that the strongest part of a labor contraction is the a. increment. b. acme. c. decrement. d. interval.
ANS: B The acme is the peak or period of greatest strength during the middle of a contraction cycle. The increment is the beginning of the contractions until it reaches the peak. The decrement occurs after the peak until the contraction ends. The interval is the period between the end of the contraction and the beginning of the next. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 289 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
10. The nurse assesses a patient whose cervix is dilated to 5 cm. What phase of labor does the nurse recognize the woman to be in? a. Latent phase b. Active phase c. Second stage d. Third stage
ANS: B The active phase of labor is characterized by cervical dilation of 4 to 6 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 299 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
7. The nurse teaching a prenatal class explains that which is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes
ANS: B The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently, but it is usually inconsistent. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 298 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
31. Thirty minutes after birth, the nurse assesses a woman's fundus as soft and boggy. What action by the nurse takes priority? a. Take the blood pressure. b. Massage the fundus. c. Notify the provider or nurse-midwife. d. Place the woman in the Trendelenburg position.
ANS: B The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. Blood pressure is important but not the priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position does not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 327 | Table 16.4 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. A student asks how pregnant women can usually tolerate the normal blood loss associated with childbirth. Which response by the nurse is best? "It is because they have a. a higher hematocrit." b. increased blood volume." c. a lower fibrinogen level." d. increased leukocytes."
ANS: B Women have a significant increase in blood volume during pregnancy, which allows them to tolerate the normal blood loss seen in delivery. The hematocrit decreases with pregnancy due to the high fluid volume. Fibrinogen levels increase with pregnancy. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 290 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Physiologic Integrity
27. 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 mucous discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.
ANS: C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 300 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products a. continues except when placental functions are reduced. b. increases as blood pressure decreases. c. diminishes as the spiral arteries are compressed. d. is not significantly affected.
ANS: C During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The maternal blood supply to the placenta gradually stops with contractions and the exchange of oxygen and waste products decreases. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 290 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity /
35. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother's right side close to midline. What is the likely position of the fetus? a. ROA b. LSP c. RSA d. LOA
ANS: C Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. This fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is positioned anteriorly in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is positioned posteriorly in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be positioned anteriorly in the left side of the pelvis with the occiput as the presenting part. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: pp. 295-296 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. The student nurse learns that which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Descent b. Engagement c. Flexion d. Station
ANS: C Flexion of the fetal head allows the smallest head diameters to pass through the pelvis. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic inlet. Station is the relationship of the fetal presenting part to the level of the ischial spines. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 299 OBJ: Integrated Process: Teaching-Learning MSC: Client Needs: Health Promotion and Maintenance
33. 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.
ANS: C Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Drying the infant with help maintain a normal temperature. Rubbing the infant does stimulate crying, but it is not the main reason for drying the infant. Removing maternal blood is also not the main reason for this action. It does not increase blood supply to the hands and feet. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 325 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
21. The nurse is answering phone calls in the OB triage area. Which patient should the nurse advise to come to the hospital soonest after labor begins? a. Gravida 2 para 1 who lives 10 minutes away b. Gravida 1 para 0 who lives 40 minutes away c. Gravida 3 para 2 whose longest previous labor was 4 hours d. Gravida 2 para 1 whose first labor lasted 16 hours
ANS: C Multiparous women usually have shorter labors than do nulliparous women. The woman described in option c is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. The other women probably have more time. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing REF: p. 305 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
30. 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 Apgar score for this infant? a. 7 b. 8 c. 9 d. 10
ANS: C The baby received 2 points for each of the categories except color. Since the infant's hands and feet were blue this category is given a grade of 1. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 326 | Table 16.3 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
39. The labor and delivery nurse is evaluating a newly admitted woman's lab and notes a hemoglobin of 9.1 mg/dL and hematocrit of 31%. What action by the nurse takes priority? a. Document the findings on the woman's chart. b. Notify the provider or nurse-midwife immediately. c. Assess for response to blood loss during and after birth. d. Place the patient on bedrest during labor.
ANS: C The normal values for a woman about to deliver are 10.5 mg/dL and 33%. Values lower than this indicate the maternal reserves may not be adequate for the normal blood loss in delivery. The nurse should use astute assessments during and after delivery to assess her response to the loss of blood. Documentation and notification should occur, but that is not the priority action. There is no indication that the woman should be restricted to bed during labor. PTS: 1 DIF: Cognitive Level: Analysis/Analyzing REF: Table 16.2 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
9. What results from the adaptation of the fetus to the size and shape of the pelvis? a. Lightening b. Lie c. Molding d. Presentation
ANS: C The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic inlet. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 293 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
28. During labor, a vaginal examination should be performed only when necessary because of the risk of a. fetal injury. b. discomfort. c. infection. d. perineal trauma.
ANS: C Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 313 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment
18. Which assessment finding could indicate hemorrhage in the postpartum patient? a. Firm fundus at the midline b. Saturation of one perineal pad in the hour after birth c. Elevated blood pressure d. Elevated pulse rate
ANS: D An increasing pulse rate is an early sign of excessive blood loss. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. If the blood volume were diminishing, the blood pressure would decrease. However, this is a later finding. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 326 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
4. To adequately care for patients, the nurse understands that labor contractions facilitate cervical dilation by a. contracting the lower uterine segment. b. enlarging the internal size of the uterus. c. promoting blood flow to the cervix. d. pulling the cervix over the fetus and amniotic sac.
ANS: D Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps to push the fetus down. Blood flow decreases to the uterus during a contraction. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering REF: p. 290 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
17. Which comfort measure should the nurse use to assist the laboring woman? a. Keep the room lights lit so that the patient and her coach can see everything. b. Offer warm, wet cloths to use on the patient's face and neck. c. Palpate her bladder every 15 minutes to assess for distention. d. Recommend frequent position changes.
ANS: D Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. Soft, indirect lighting is more soothing than irritating bright lights. Women in labor become hot and perspire. Cool cloths are much better. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 316 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
22. 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 unchanged from admission. Membranes are intact. What action by the nurse is most appropriate? a. Prepare the woman for a cesarean birth. b. Admit the woman for extended observation. c. Discharge the woman with a sedative so she can rest. d. Provide discharge teaching on signs of true labor.
ANS: D The situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. There is no need to prepare her for a cesarean birth, admit her, or send her home with sedation. PTS: 1 DIF: Cognitive Level: Application/Applying REF: p. 298 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
25. What finding should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Contractions lasting 90 seconds c. FHR in the 140s d. Meconium-stained amniotic fluid
ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. Expected FHR range is from 110 to 160. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 315 | Safety Alert Box OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
37. A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate "labor is getting closer to starting." The nurse informs the woman that which of the following is a sign that labor may begin soon? a. Weight gain of 1.5 to 2 kg (3 to 4 lb) b. Increase in fundal height c. Urinary retention d. Surge of energy
ANS: D Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, the result of water loss caused by electrolyte shifts, which in turn are caused by changes in the estrogen and progesterone levels. When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding REF: p. 298 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance