Maternal Child Nursing Rasmussen Module 3 INTRA-PARTUM CARE NCLEX Prep
The fetus of a woman in labor is in a vertex presentation and at a -1 station. The nurse would interpret this to mean that the fetal head is: A) at the ischial spines. B) engaged. C) floating. D) crowning.
C) floating.
When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture? A) Meconium-stained amniotic fluid B) Fetus presenting in an LOA position C) Maternal pulse of 90 to 95 beats/min D) Blood-tinged vaginal discharge at full dilation
A) Meconium-stained amniotic fluid
After assessment, the nurse determines that a pregnant patient's fetus has a face presentation that is pointing to the patient's left side with transverse pointing. How should the nurse document this assessment finding? A) LCT B) LMT C) LOT D) ROA
B) LMT
The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply. A) False labor contractions are irregular. B) True labor contractions disappear when asleep. C) False labor contractions lead to cervical dilation. D) True labor contractions occur in the abdomen and groin. E) False labor contractions do not increase in duration, frequency, and intensity.
A) False labor contractions are irregular. E) False labor contractions do not increase in duration, frequency, and intensity.
The nurse providing care to patients in the labor and delivery suite desires to support the 2020 National Health Goals to reduce maternal and infant mortality after labor and birth. Which action should the nurse perform to support these goals? A) Support laboring patients through the use of controlled breathing techniques. B) Encourage laboring patients to use analgesia to control painful contractions. C) Recommend the use of epidural and spinal anesthesia to aid in the labor process. D) Apply specific infection control practices during the labor and birthing processes.
A) Support laboring patients through the use of controlled breathing techniques.
The nurse is teaching a pregnant patient the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor? A) The fetal head bends forward onto the chest. B) The fetal head rotates into a transverse position. C) The head extends so that the face and chin are born. D) The shoulders move into an anteroposterior position.
A) The fetal head bends forward onto the chest.
As a woman enters the second stage of labor, which would the nurse expect to assess? A) feelings of being frightened by the change in contractions B) reports of feeling hungry and unsatisfied C) falling asleep from exhaustion D) expressions of satisfaction with her labor progress
A) feelings of being frightened by the change in contractions
To assess the frequency of a woman's labor contractions, the nurse would time: A) the beginning of one contraction to the beginning of the next. B) the end of one contraction to the beginning of the next. C) the interval between the acme of two consecutive contractions. D) how many contractions occur in 5 minutes.
A) the beginning of one contraction to the beginning of the next.
A woman's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best? A) "It prevents distention of the bladder." B) "It relieves pressure on the fetal head." C) "It aids contraction of the uterus following birth." D) "It is done primarily for the care provider's benefit."
B) "It relieves pressure on the fetal head."
During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs? A) Turn the patient onto the left side. B) Assess fetal heart rate for fetal safety. C) Test a sample of amniotic fluid for protein. D) Instruct to bear down with the next contraction.
B) Assess fetal heart rate for fetal safety.
Which of the following would be a danger signal of labor for a woman in labor? A) Blood-tinged vaginal discharge at full dilation B) Meconium-stained amniotic fluid C) Maternal pulse of 90 to 95 beats per minute D) Fetus presenting in an LOA position
B) Meconium-stained amniotic fluid
After pelvic measurements, a patient who is 20 weeks' pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address this? A) Powers B) Passageway C) Passenger D) Psychological outlook
B) Passageway
While conducting Leopold maneuvers, the nurse determines that the fourth maneuver does not need to be done. What information caused the nurse to make this decision? A) The fetus is in a cephalic presentation. B) The fetus is not in a cephalic presentation. C) The nurse palpated angular bumps and nodules. D) The nurse palpated a round and hard mass that moves freely.
B) The fetus is not in a cephalic presentation.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? A) Help the woman to sit up in a semi-Fowler's position. B) Turn her or ask her to turn to her side. C) Administer oxygen at 3 to 4 L by nasal cannula. D) Ask her to pant with the next contraction.
B) Turn her or ask her to turn to her side.
A woman is admitted to a labor unit in active labor. Which assessment would alert you to the possibility that she may have difficulty accepting this child? A) "I'm so tired of being pregnant." B) "I haven't been able to sleep well lately." C) "I want this baby to be a boy." D) "I am so exhausted."
C) "I want this baby to be a boy."
Dilation follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement? A) 3 to 4 cm B) 7 to 8 cm C) 8 to 10 cm D) 12 to 14 cm
C) 8 to 10 cm
The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care? A) A woman should be left entirely alone during this period. B) A woman will rarely speak or laugh during this period. C) A woman may spend time thinking about what is happening to her. D) No nursing care is needed to be done during this time.
C) A woman may spend time thinking about what is happening to her.
After delivery of the placenta, a patient's uterus is sluggish to contract. What should the nurse prepare to do to assist the patient at this time? A) Administer intravenous fluids. B) Measure blood pressure every 15 minutes. C) Administer oxytocin as prescribed. D) Prepare to administer blood products as prescribed.
C) Administer oxytocin as prescribed.
A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her? A) Lie supine so the tracing does not show a shadow. B) Avoid flexing her knees so her abdomen is not tense. C) Lie on her side so she is comfortable. D) Avoid using her call bell to reduce interference.
C) Lie on her side so she is comfortable.
During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time? A) Risk for fluid volume deficit B) Anxiety related to stress of labor C) Risk for ineffective breathing pattern related to breathing exercises D) Powerlessness related to duration of labor
C) Risk for ineffective breathing pattern related to breathing exercises
To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? A) lying supine with legs in lithotomy stirrups B) squatting while holding her breath C) head elevated, grasping knees, breathing out D) lying on side, arms grasped on abdomen
C) head elevated, grasping knees, breathing out
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? A) Test a sample of amniotic fluid for protein. B) Ask her to bear down with the next contraction. C) Elevate her hips to prevent cord prolapse. D) Assess fetal heart rate for fetal safety.
D) Assess fetal heart rate for fetal safety.
During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding? A) Variable decelerations that are too unpredictable to count B) Fetal baseline rate increasing at least 5 mm Hg with contractions C) A shallow deceleration occurring with the beginning of contractions D) Fetal heart rate declining late with contractions and remaining depressed
D) Fetal heart rate declining late with contractions and remaining depressed
The nurse is determining care for a patient entering the active phase of labor. Which outcome would be the most appropriate for the patient at this time? A) Patient will develop an irresistible urge to push. B) Patient will combat feelings of nausea to prevent vomiting. C) Patient will remain in the supine position during contractions. D) Patient will adjust body to attain the most comfortable position.
D) Patient will adjust body to attain the most comfortable position.
The nurse is concerned that a patient in the second stage of labor will experience a drop in blood pressure. What should the nurse do to prevent this from occurring? A) Position the patient supine. B) Encourage oral fluid intake. C) Administer intravenous fluids. D) Position the patient side-lying
D) Position the patient side-lying
A pregnant patient in labor is being encouraged to push with contractions. In which position should the nurse assist to help the patient at this time? A) Squatting while holding the breath B) Lying on side, arms grasped on abdomen C) Lying supine with legs in lithotomy stirrups D) Semi-Fowler's position with legs bent against the abdomen
D) Semi-Fowler's position with legs bent against the abdomen
The nurse is preparing to assess the duration of contractions for a patient in labor. Which process should the nurse use to time the contractions? A) Number of contractions that occur in 5 minutes B) The end of one contraction to the beginning of the next C) The interval between the acmes of two consecutive contractions D) The interval between the beginning and the end of one contraction
D) The interval between the beginning and the end of one contraction
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? A) a shallow deceleration occurring with the beginning of contractions B) variable decelerations, too unpredictable to count C) fetal baseline rate increasing at least 5 mm Hg with contractions D) fetal heart rate declining late with contractions and remaining depressed
D) fetal heart rate declining late with contractions and remaining depressed
During the second stage of labor, a woman is generally: A) very aware of activities immediately around her. B) anxious to have people around her. C) no longer in need of a support person. D) turning inward to concentrate on body sensations.
D) turning inward to concentrate on body sensations.
A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress? a."You are still 2 cm dilated, but the cervix is thinning out nicely." b."There has been no further dilation, effacement is progressing." c.Don't mention anything to the client yet, wait for further dilation to occur. d." You haven't dilated any further, but hang in there, it will happen eventually."
a."You are still 2 cm dilated, but the cervix is thinning out nicely."
The nurse providing care for the laboring woman understands that accelerations with fetal movement: a.Are reassuring. b.Are caused by umbilical cord compression. c.Warrant close observation. d.Are caused by uteroplacental insufficiency.
a.Are reassuring.
Which of the following findings would be a cause for concern for a nurse who is monitoring an obstetric patient who is in early labor? Select all that apply. a.Biparietal diameter of less than 9.25 cm b.Vertex presenting part c.Transverse lie d.General flexion attitude e.Android pelvis
a.Biparietal diameter of less than 9.25 cm c.Transverse lie e.Android pelvis
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: a.Change in position. b.Oxytocin administration. c.Regional anesthesia. d.Intravenous analgesic.
a.Change in position.
When performing vaginal examinations on a laboring woman, the nurse should be guided by what principle? a.Cleanse the vulva and perineum before and after the examination as needed. b.Wear a clean glove lubricated with tap water to reduce discomfort. c.Perform the examination every hour during the active phase of the first stage of labor. d.Perform an examination immediately if active bleeding is present.
a.Cleanse the vulva and perineum before and after the examination as needed.
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 that 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.
Fetal circulation can be affected by many factors during labor. Accurate assessment of the laboring woman and fetus requires knowledge of these expected adaptations. Which factor will not affect fetal circulation during labor? a.Fetal position b.Uterine contractions c.Blood pressure d.Umbilical cord blood flow
a.Fetal position
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: a.The examiner's hand should be placed over the fundus before, during, and after contractions. b.The frequency and duration of contractions are measured in seconds for consistency. c.Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. d.The resting tone between contractions is described as either placid or turbulent.
a.The examiner's hand should be placed over the fundus before, during, and after contractions.
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. 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.
Fetal well-being during labor is assessed by: a.The response of the fetal heart rate (FHR) to uterine contractions (UCs). b.Maternal pain control. c.Accelerations in the FHR. d.An FHR greater than 110 beats/min.
a.The response of the fetal heart rate (FHR) to uterine contractions (UCs).
A young woman recently gave birth to a healthy 7 lb, 6 oz baby girl. There were no complications during the birth, and the mother appears to be well. Which of the following should the nurse do to assess this client's psychological state after the pregnancy? a.encourage the client to talk about her birthing experience with the nurse and others b.ask her about her family history related to mental illness c.refer the client to psychologist who specializes in postpartum depression d.quiz the client on her knowledge of current events to make sure she is lucid
a.encourage the client to talk about her birthing experience with the nurse and others
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contraction or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply. a.increase in duration, frequency, and intensity b.often disappear with ambulation or sleep c.begin irregularly but become regular and predictable d.begin and remain irregular e.felt first in lower back and sweep around to the abdomen in a wave f.felt first abdominally and remain confined to the abdomen and groin
a.increase in duration, frequency, and intensity c.begin irregularly but become regular and predictable e.felt first in lower back and sweep around to the abdomen in a wave
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 may 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 group of fetal monitoring experts (National Institute of Child Health and Human Development, 2008) recommends that fetal heart rate (FHR) tracings demonstrate certain characteristics to be described as reassuring or normal (category I). These characteristics include: a.Bradycardia not accompanied by baseline variability. b.Early decelerations, either present or absent. c.Sinusoidal pattern. d.Tachycardia.
b.Early decelerations, either present or absent.
Which test is performed to determine whether membranes are ruptured? a.Urine analysis b.Fern test c.Leopold maneuvers d.AROM
b.Fern test
Which statement is inaccurate with regard to normal labor? a.A single fetus presents by vertex. b.It is completed within 8 hours. c.A regular progression of contractions, effacement, dilation, and descent occurs. d.No complications are involved.
b.It is completed within 8 hours.
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.
b.The cervix cannot be felt during a vaginal examination.
Concerning the third stage of labor, nurses should be aware that: a.The placenta eventually detaches itself from a flaccid uterus. b.The duration of the third stage may be as short as 3 to 5 minutes. 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.The duration of the third stage may be as short as 3 to 5 minutes.
Under which circumstance would a nurse not perform a vaginal examination on a patient in labor? 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 nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment? a.detection of rales b.detection of a herpes virus infection c.detection of a respiratory infection d.detection of anemia
b.detection of a herpes virus infection
True or False: an infant born by cesarean birth is usually able to establish respirations more easily than one born vaginally. a.true b.false
b.false
A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates her understanding of the instructions when the woman states: a."True labor contractions will subside when I walk around." b."True labor contractions will cause discomfort over the top of my uterus." c."True labor contractions will continue and get stronger even if I relax and take a shower." d."True labor contractions will remain irregular but become stronger."
c."True labor contractions will continue and get stronger even if I relax and take a shower."
Which description of the phases of the second stage of labor is accurate? a.Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes b.Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes c.Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies d.Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes
c.Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies
A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: a.Narcotics. b.Barbiturates. c.Methamphetamines. d.Tranquilizers.
c.Methamphetamines.
Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? a.The healthy newborn should be taken to the nursery for a complete assessment. b.After drying, the infant should be given to the mother wrapped in a receiving blanket. c.Skin-to-skin contact of mother and baby should be encouraged. d.The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.
c.Skin-to-skin contact of mother and baby should be encouraged.
Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased? a.Semirecumbent b.Sitting c.Squatting d.Side-lying
c.Squatting
Fetal bradycardia is most common during: a.Maternal hyperthyroidism. b.Fetal anemia. c.Viral infection. d.Tocolytic treatment using ritodrine.
c.Viral infection.
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth? a.fetus in partial extension with brow presenting to the birth canal b.fetus in complete extension with back arched c.head flexed forward so much that the chin touches the sternum d.chin in moderately flexed military position
c.head flexed forward so much that the chin touches the sternum
A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure? a.to prevent the woman from falling out of bed b.to aid the woman as she pushes during labor c.to prevent supine hypotension syndrome d.to decrease the heart rate of the fetus
c.to prevent supine hypotension syndrome
Which sign does not precede the onset of labor? a.A return of urinary frequency as a result of increased bladder pressure b.Persistent low backache from relaxed pelvic joints c.Stronger and more frequent uterine (Braxton Hicks) contractions d.A decline in energy, as the body stores up for labor
d.A decline in energy, as the body stores up for labor
Which of the following statements is not used to describe a characteristic of a uterine contraction? 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)
The most common cause of decreased variability in the FHR that lasts 30 minutes or less is: a.Altered cerebral blood flow. b.Fetal hypoxemia. c.Umbilical cord compression. d.Fetal sleep cycles.
d.Fetal sleep cycles.
Which of the following would not be included in a labor nurse's plan of care for an expectant mother? 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
If a woman complains of back labor pain, the nurse might 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.
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? a.Call for help. b.Insert a Foley catheter. c.Start oxytocin (Pitocin). d.Notify the primary health care provider immediately.
d.Notify the primary health care provider immediately.
In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: a.The woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. b.Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. c.Having the woman point her toes reduces leg cramps. d.The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.
d.The endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.
A nurse is monitoring a client during the second stage of labor. Which finding in the mother should cause concern for the nurse? a.an increase in white blood cell count to 30,000 cells/mm3 b.an increase in the specific gravity of urine to 1.030 c.an increase in body temperature to 99.6 degrees F d.a rise in systolic blood pressure of 30 mm Hg with each contraction
d.a rise in systolic blood pressure of 30 mm Hg with each contraction
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? a.decreased plasma fibrinogen levels b.increased blood coagulation time c.increased blood glucose levels d.increased white blood cell count
d.increased white blood cell count
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time> a.hold the breath while pushing during contractions b.pant while pushing c.begin pushing as soon as the cervix has dilated to 8 cm d.push with contractions and rest between them
d.push with contractions and rest between them
A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor? a.third stage b.first stage c.fourth stage d.second stage
d.second stage
A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet? a.occipitofrontal b.suboccipitobregmatic c.occipitomental d.transverse
d.transverse
A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? a.a woman should be allowed to assume a supine position b.the support person's access to the client should be limited to prevent the client from becoming so overwhelmed c.routine intravenous fluid should be implemented d.women should be able to move about freely throughout labor
d.women should be able to move about freely throughout labor
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
With regard to primary and secondary powers, the maternity nurse should understand that: a.Primary powers are responsible for effacement and dilation of the cervix. b.Effacement generally is well ahead of dilation in women giving birth for the first time
they are more together in subsequent pregnancies. c.Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. d.Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs. ; a.Primary powers are responsible for effacement and dilation of the cervix.
