Nursing Care of the Family During Labor and Birth 44Qw/exp *GOOD*

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 (The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-infant attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The nursing activities would be (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering the infant with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborn's physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the infant to the partner or mother when he or she is ready.)

Vaginal examinations should be performed by the nurse under which of these circumstances. (Select all that apply.) 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 E) When bright, red bleeding is observed

A) An admission to the hospital at the start of labor C) On maternal perception of perineal pressure or the urge to bear down D) When membranes rupture Rationale: Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM) a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. Examinations are never done by the nurse if vaginal bleeding is present since the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

For the labor nurse, care of the expectant mother begins with which situations? (Select all that apply.) 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 E) Moderately painful contractions

A) The onset of progressive, regular contractions B) The bloody, or pink, show C) The spontaneous rupture of membranes Rationale: Labor care begins with the onset of progressive, regular contractions. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when the blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when amniotic fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Pain is subjective. The onset of progressive, regular contractions signals the beginning of labor; not the intensity of the pain.

For the labor nurse, care of the expectant mother begins with which situations? Select all that apply. 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 E. Moderately painful contractions

A, B, C (Labor care begins with the onset of progressive, regular contractions. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when the blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when amniotic fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Pain is subjective. The onset of progressive, regular contractions signals the beginning of labor, not the intensity of the pain.)

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 finds that the pregnant patient has impaired urinary elimination. Which interventions should be performed by the nurse to relieve the patient's problem? Select all that apply. A. Encourage the patient to urinate every 2 hours. B. Catheterize the patient immediately for voiding. C. Palpate patient's bladder superior to symphysis. D. Ask the patient to place the hand in running water. E. Provide effleurage massage to the patient frequently.

A, C, D (Impaired urinary elimination occurs as a result of sensory impairment caused by the labor process. Therefore the nurse has to perform interventions that help in emptying the patient's bladder every 2 hours. The nurse should encourage the patient to void every 2 hours to avoid bladder distention. The nurse can use running water to stimulate voiding by asking the patient to keep her hands in the running water. The nurse should palpate the patient's bladder on a frequent basis to detect the inability to void. The nurse should not catheterize the patient immediately for voiding, because it may result in trauma to the bladder. Effleurage helps in reducing pain but does not help stimulate voiding in the patient.)

The nurse assesses a pregnant patient and reports to the primary health care provider (PHP) that the patient is in the second stage of labor. Which of the patient's signs enabled the nurse to give such a report to the PHP? Select all that apply. A. Urge to defecate B. Cheeks appear to be flushing C. Cervical dilation of 10 cm D. Brownish discharge of mucus from the vagina E. Premature urge to bear down

A, C, E (After an assessment, the nurse reports to the PHP that a pregnant patient is in the second stage of labor because the patient has a cervical dilation of 10 cm (fully dilated). The patient has a premature urge to bear down and an urge to defecate. The patient may have flushed cheeks in the active phase of first stage of labor, but it is not a sign of second stage of labor. Brownish discharge of mucus is a sign of latent phase of first stage of labor, but does not appear in the second stage of labor.)

Women who have participated in childbirth education classes often bring a birth plan with them to the hospital. Which items might this plan include? (Select all that apply.) a. Presence of companions b. Clothing to be worn c. Care and handling of the newborn d. Medical interventions e. Date of delivery

ANS: A, B, C, D The presence of companions, clothing to be worn, care and handling of the newborn, medical interventions, and environmental modifications all might be included in the couple's birth plan. Other items include the presence of nonessential medical personnel (students), labor activities such as the tub or ambulation, preferred comfort and relaxation methods, and any cultural or religious requirements. The expected date of delivery would not be part of a birth plan unless the client is scheduled for an elective cesarean birth.

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.) a. Nonreassuring or abnormal FHR pattern b. Inadequate uterine relaxation c. Vaginal bleeding d. Prolonged second stage e. Prolapse of the cord

ANS: A, B, C, E A nonreassuring or abnormal FHR pattern, inadequate uterine relaxation, vaginal bleeding, infection, and cord prolapse all constitute an emergency during labor that requires immediate nursing intervention. A prolonged second stage of labor after the upper limits for duration is reached. This is 3 hours for nulliparous women and 2 hours for multiparous women.

Which statement concerning the third stage of labor is correct? 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 appears before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.

ANS: B Active management facilitates placental separation and expulsion, reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhaging.

Which clinical finding indicates that the client has reached the second stage of labor? a. Amniotic membranes rupture. b. Cervix cannot be felt during a vaginal examination. c. Woman experiences a strong urge to bear down. d. Presenting part of the fetus is below the ischial spines.

ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. The ROM has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting fetal part is below the level of the ischial spines. This urge can occur during the first stage of labor, as early as with 5 cm dilation.

The first 1 to 2 hours after birth is sometimes referred to as what? a. Bonding period b. Third stage of labor c. Fourth stage of labor d. Early postpartum period

ANS: C The first 2 hours of the birth are a critical time for the mother and her baby and is often called the fourth stage of labor. Maternal organs undergo their initial readjustment to a nonpregnant state. The third stage of labor lasts from the birth of the baby to the expulsion of the placenta. Bonding will occur over a much longer period, although it may be initiated during the fourth stage of labor.

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and a tightening of the abdominal muscles. When is it appropriate to instruct the client to use this maneuver? a. During the second stage to enhance the movement of the fetus b. During the third stage to help expel the placenta c. During the fourth stage to expel blood clots d. Not at all

ANS: D The client should not be instructed to use this maneuver. This process stimulates the parasympathetic division of the autonomic nervous system and produces a vagal response (decrease in heart rate and blood pressure.) An alternative method includes instructing the client to perform open-mouth and open-glottis breathing and pushing.

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

ANS: C The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus, which may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.

A 25-year-old gravida 3, para 2 client gave birth to a 9-pound, 7-ounce boy, 4 hours ago after augmentation of labor with oxytocin (Pitocin). She presses her call light, and asks for her nurse right away, stating "I'm bleeding a lot." What is the most likely cause of postpartum hemorrhaging in this client? a. Retained placental fragments b. Unrepaired vaginal lacerations c. Uterine atony d. Puerperal infection

ANS: C This woman gave birth to a macrosomic infant after oxytocin augmentation. Combined with these risk factors, uterine atony is the most likely cause of bleeding 4 hours after delivery. Although retained placental fragments may cause postpartum hemorrhaging, it is typically detected within the first hour after delivery of the placenta and is not the most likely cause of the hemorrhaging in this woman. Although unrepaired vaginal lacerations may also cause bleeding, it typically occurs in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding that is, however, typically detected 24 hours postpartum.

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse's highest priority in this situation? 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 (FHR) and pattern.

ANS: D The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the ROM to ascertain fetal well-being, and the findings should be documented. The ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary health care provider after ROM occurs and the fetal well-being and response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.

Which characteristic of a uterine contraction is not routinely documented? a. Frequency: how often contractions occur b. Intensity: strength of the contraction at its peak c. Resting tone: tension in the uterine muscle d. Appearance: shape and height

ANS: D Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not routinely charted.

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 (Active management facilitates placental separation and expulsion, thus reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage.)

The nurse is caring for a Hispanic patient who has given birth to a baby. When does the nurse expect the patient to start breastfeeding? A. First hour after birth B. When the milk comes C. When the infant cries D. After the patient has rested

B (Some patients often wish to breastfeed after the ejection of the milk. The patient cannot be given instruction to breastfeed 1 hour after birth. The patient may require rest, but breastfeeding should be encouraged only after the milk ejection. Some patients prefer to breastfeed during the infant's reactive state, but patients of a Hispanic background may not choose to do this, as it may not fall within their cultural belief system. The nurse should always respect the cultural beliefs of the patient.)

Which test is performed to determine if membranes are ruptured? A) Urine analysis B) Fern test C) Leopold maneuvers D) Artificial Rupture of Membranes (AROM)

B) Fern test Rationale: A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? A. Help the patient to lie in supine position on the bed. B. Encourage the patient to sit in hands-and-knees position. C. Place a pillow under the patient's hip when lying in supine position. D. Ask the patient to lie in lateral position on the opposite side of the fetal spine.

B (The nurse should place the patient in a position that helps the rotation of the fetal occiput from a posterior to an anterior position. Therefore the nurse should encourage the patient to sit in hands-and-knees position, as it increases the pelvic diameter, allowing the head to rotate toward anterior position. The patient should not lie in supine position, as it may cause postural hypotension. Placing a pillow under the patient's hip when lying in supine position helps prevent supine hypotensive syndrome, but does not help in delivering the baby. The nurse should not ask the patient to lie in lateral position on the opposite side of the fetal spine, as it increases counter pressure on the back. Instead, lying in lateral position on the same side of the fetal spine will help the fetus rotate toward the posterior, as the gravity pulls the fetal back forward.)

The nurse is assessing a pregnant patient in the last week of gestation. The nurse observes that the patient has flushed cheeks, uterine contractions (UCs) of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. What stage of labor should the nurse infer that the patient is in based on these observations? A. Latent phase B. Active phase C. Transition phase D. Active pushing phase

B (The patient has flushed cheeks, UCs of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. These symptoms are observed during the active phase of labor. The symptoms of the patient do not correlate with the latent, transition, or active pushing phases (second stage) of labor. In the latent phase of labor, the UCs are 30 to 45 seconds with a frequency of 5 to 30 minutes, and the mucus is pale pink. In the transition phase, the UCs are 45 to 90 seconds with a frequency of 2 to 3 minutes, and the mucus appears bloody. In the active pushing phase of the second stage of labor, the UCs are 90 seconds with a frequency of 2 to 2.5 minutes.)

A patient in labor exhibits flushed cheeks. The nurse records the uterine contractions in the patient as being 3 to 5 minutes apart and lasting for about 1 minute. What nursing intervention is most effective to assess the patient's status during this phase of labor? A. Check blood pressure every 2 hours. B. Note patient's appearance and mood every 15 minutes. C. Assess the patient's temperature every 2 hours until membranes rupture. D. Document

B (The patient is experiencing uterine contractions that are 3 to 5 minutes apart and last for about 60 seconds (1 minute). The patient also exhibits flushed cheeks. These findings indicate that the patient is in the active phase of the first stage of labor. The nursing assessment in the active stage of labor is to check the patient's appearance and mood every 15 minutes, or 4 times in an hour. The patient's mood and energy levels fluctuate, and therefore the nurse should constantly assess them to ensure effective patient care. The patient's blood pressure should be assessed every 30 minutes. The nurse should assess the patient's body temperature every 4 hours until membrane rupture and thereafter every 2 hours. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.)

Which patients are more susceptible to soft-tissue damage with vaginal deliveries? Select all that apply. A. Multiparous patients B. Nulliparous patients C. Patients needing forceps delivery D. Patients with fetal vertex presentation E. Patients with fetal breech presentatio

B, C, E (A nulliparous patient has rigid perineal tissue making it susceptible to injury. Fetal breech presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps delivery also increases the risk of injury due to undue stretch of the perineum. Multiparous patients have stretchable perineal tissues, which are less likely to get injured during childbirth. Fetal vertex presentation causes the least amount of tissue damage.)

The nurse is caring for a Southeast Asian patient who gave birth to a child. What interventions can the nurse perform to promote bonding between the newborn and the family? Select all that apply. A. Placing the hand on the infant's head B. Encouraging the sibling to hold the baby C. Explaining the molding of the infant's head D. Praising the infant's appearance and health E. Explaining the dusky appearance of the infant

B, C, E (The parents may be worried about the newborn's dusky appearance. Therefore the nurse should properly explain to the parents that the baby may initially appear dusky. The color may become normal once the circulation is established. Siblings may be encouraged to hold the newborn to promote bonding between them. The infant's head is molded due to the narrowness of the birth canal and the pelvic structures. This is to be explained to the parents. Southeast Asian patients consider the head to be the sacred part of the human body and should not be touched. Hence, the nurse should avoid placing hand on the infant's head. The Southeast Asian population considers any praise of the infant as harmful, as they believe the jealous spirits will take away the baby.)

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 (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.)

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 (The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus that may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses this assessment is performed more frequently.)

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? The laceration: A. Also involves the anterior rectal wall. B. Continues through the anal sphincter muscle. C. Extends through muscles of the perineal body. D. Extends through the skin and structures superficial to muscles

D (A first-degree laceration extends through the skin and structures superficial to muscles. A second-degree laceration extends through muscles of the perineal body. A third-degree laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall.)

During an assessment, the nurse is instructed to determine the position of the fetal head in a pregnant patient. What should the nurse do to determine whether the fetal head is flexed or extended? A. Palpate the fetal head with the palmar surface of the fingertips of the right hand. B. Identify the fetal part that occupies the fundus in the uterus of the pregnant patient. C. Palpate the smooth convex contour of the fetal back using the palmar surface of one hand. D. Grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly.

D (Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. Therefore the nurse should grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly in order to determine whether the fetal head is flexed or extended. Identifying the fetal part that occupies the fundus of the patient helps to identify the fetal position. The fetal head is palpated with the palmar surface of the fingertips using both hands, but not with only the right hand to determine the cephalic prominence. Palpation of the smooth convex contour of the fetal back and irregularities using the palmar surface of one hand is not used to determine the attitude of the fetal head. This maneuver helps identify the feet, hands, and elbows of the fetus.)

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

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.

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.

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

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.

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.

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.

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

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.

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.

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

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.

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.