Chapter 13: Nursing Care During Labor and Birth

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

a. Helping the woman manage the pain

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.

a. Inform the mother that the rate is normal.

Which comfort measure should a nurse use to assist a laboring woman to relax? a. Recommend frequent position changes. b. Palpate her filling bladder every 15 minutes. c. Offer warm wet cloths to use on the client's face and neck. d. Keep the room lights lit so the client and her coach can see everything.

a. Recommend frequent position changes.

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a. 18-gauge b. 20-gauge c. 22-gauge d. 24-gauge

a. 18-gauge

Which assessment finding could indicate hemorrhage in the postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours

a. Elevated pulse rate

The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine d. The client's understanding of the event

a. Fetal heart rate

The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a. Soft boggy uterus b. Maternal temperature of 99° F c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics e. Half of a lochia pad saturated in the first hour after birth

a. Soft boggy uterus c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics

When using the second Leopold's maneuver in fetal assessment, the nurse would palpate (the): a. both sides of the maternal abdomen. b. lower abdomen above the symphysis pubis. c. both upper quadrants of the maternal abdomen . d. lower abdomen for flexion of the presenting part.

a. both sides of the maternal abdomen.

During labor a vaginal examination should be performed only when necessary because of the risk of: a. infection. b. fetal injury. c. discomfort. d. perineal trauma.

a. infection.

If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to: a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position.

a. massage the fundus.

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

a. reduce heat loss from evaporation.

Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process

d. Anxiety related to imminent birth process

At 5 minutes after birth, the nurse assesses that the neonate's heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a. 7 b. 8 c. 9 d. 10

b. 8

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c Green and thick d. Yellow and cloudy with foul odor

b. Clear with bits of vernix caseosa

Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor? a. Length of second-stage labor is 2 hours. b. Client has received an epidural for pain control during the labor process. c. Client is using breathing techniques during contractions to maximize pain relief. d. Client is receiving parenteral fluids during the course of labor to maintain hydration.

b. Client has received an epidural for pain control during the labor process.

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed.

b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. e. Remove wet linen as needed.

A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time? a. Performing more frequent vaginal exams will not make the labor go any quicker. b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c. Tell the client that she will check every 30 minutes. d. Medicate the client as needed for anxiety so that the labor can progress.

b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.

The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour

b. Every 30 minutes

The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a. Place the catheter as quickly as possible. b. Place a small pillow under the patient's left hip. c. Omit the use of a cleansing agent, such as Betadine. d. Set up the catheter tray before positioning the patient.

b. Place a small pillow under the patient's left hip

The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head? a. Expulsion b. Restitution c. Internal rotation d. External rotation

b. Restitution

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

b. The vulva bulges and encircles the fetal head.

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

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

A nursing priority during admission of a laboring client who has not had prenatal care is: a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care.

b. identifying labor risk factors.

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. The Apgar score for this infant is: a. 7. b. 8. c. 9. d. 10.

c. 9.

The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse's priority action with this procedure? a. Perform Leopold's maneuvers. b. Determine the color of the amniotic fluid. c. Assess the fetal heart rate immediately after the procedure. d. Prepare the patient for a change in her pain level after the procedure.

c. Assess the fetal heart rate immediately after the procedure.

A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a. Obtain a fetal heart rate. b. Determine the estimated due date. c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat.

c. Auscultate anterior and posterior breath sounds.

The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior. d. Determine whether the mother is too fatigued to interact normally with her infant.

c. Document this evidence of normal early maternal-infant attachment behavior.

The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time? a. To apply internal monitoring electrodes b. To assess for Goodell's sign c. To determine cervical dilation and effacement d. To determine strength of contractions

c. To determine cervical dilation and effacement

The nurse is preparing to perform Leopold's maneuvers. Why are Leopold's maneuvers used by practitioners? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position

c. To determine the best location to assess the fetal heart rate

A client at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: a. fetal movement. b. irregular contractions for 1 hour. c. a trickle of fluid from the vagina. d. thick pink or dark red vaginal mucus.

c. a trickle of fluid from the vagina.

The nurse examines a primipara's cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action? a. Palpate her bladder for fullness. b. Assess the frequency and duration of her contractions. c. Determine who will stay with the patient for the birth. d. Encourage the patient to exhale in short breaths with contractions.

d. Encourage the patient to exhale in short breaths with contractions.

Which client at term should go to the hospital or birth center the 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 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours

d. Gravida 3, para 2, whose longest previous labor was 4 hours

Which should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid

d. Meconium-stained amniotic fluid

The gynecologist performs an amniotomy. What will the nurse's role include immediately following the procedure? a. Assessing for ballottement b. Conducting a pH and/or fern test c. Labeling of specimens for chromosomal analysis d. Recording the character and amount of amniotic fluid

d. Recording the character and amount of amniotic fluid

A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely: a. abnormal labor. b. a sign that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor.

d. common during the transition phase of labor.

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

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

The nurse has given the newborn an Apgar score of 5. She should then: a. begin ventilation and compressions. b. do nothing except place the infant under a radiant warmer. c. observe the infant and recheck the score after 10 minutes. d. gently stimulate by rubbing the infant's back while administering O2.

d. gently stimulate by rubbing the infant's back while administering O2.