Chapter 15: Nursing Care of a Family During Labor and Birth

4. 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.

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 347 Feedback: Measuring from the beginning of one contraction to the next marks the time between contractions.

2. 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

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 346 Feedback: Meconium staining indicates the fetus has suffered anoxia.

3. 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

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 341 Feedback: Full dilation of the cervix is 8 to 10 cm.

5. 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.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 356 Feedback: The best position for all women during labor is on their side.

12. 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

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Understand Page: 366 Feedback: An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.

10. 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.

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 350-352 Feedback: Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.

1. 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.

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Understand Page: 334-335 Feedback: A fetus is not engaged until the presenting part reaches the ischial spines.

23. 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.

Ans: A Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 335-336 Feedback: The cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation, and expulsion. In descent, the fetal head bends forward onto the chest once the head presses on the sacral nerves at the pelvic floor. The fetal head rotates into a transverse position prior to expulsion. The head extends so that the face and chin are born during extension. The shoulders move into an anteroposterior position during external rotation.

9. 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

Ans: A Client Needs: Psychosocial Integrity Cognitive Level: Understand Page: 342 Feedback: The nature of contractions changes so drastically- the urge to push is very strong-that this can be frightening.

15. The fetus of a patient in labor is in a vertex presentation and at a -1 station. How should the nurse interpret the location of the fetal head? A) Floating B) Engaged C) Crowning D) At the ischial spines

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 334-335 Feedback: Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. The degree of engagement is established by vaginal and cervical examination. Station refers to the relationship of the presenting part of the fetus to the level of the ischial spines. If the presenting part is above the spines, the distance is measured and described as minus stations, such as -1. The fetal head is currently floating. The head would be engaged if it were at the level of the ischial spines. Crowning is when the top of the fetal head is visible and birth is imminent.

14. 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.

Ans: C Client Needs: Psychosocial Integrity Cognitive Level: Apply Page: 341 Feedback: Women need a support person with them during all stages of labor.

7. 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.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 358 Feedback: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

16. 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

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 352 Feedback: Meconium staining means that the fetus has lost rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. The fetal presentation is not assessed during membrane rupture. The maternal pulse rate of 90 to 95 beats/min is expected during labor. Blood-tinged vaginal discharge at full dilation is an expected finding.

21. 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.

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 327 Feedback: Nurses can help the nation achieve the 2020 National Health Goals for reducing maternal and infant mortality after labor and birth by teaching patients as much as possible about labor, so they are able to use as little analgesia and anesthesia as possible. The less anesthesia and analgesia used, the fewer the complications, which can result in fetal or maternal death. One approach would be to support laboring patients through the use of controlled breathing techniques. Infection control practices are not identified as strategies to reduce maternal and infant mortality after labor and birth.

17. 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.

Ans: A, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 339 Feedback: False labor contractions are irregular. True labor contractions increase in duration, frequency, and intensity. False labor contractions disappear when asleep and occur in the abdomen and groin. True labor contractions lead to cervical dilation.

28. 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

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 334 Feedback: Fetal position is the relationship of the presenting part to a specific quadrant and side of the patient's pelvis. The maternal pelvis is divided into four quadrants according to the mother's right and left. Four parts of a fetus are landmarks to describe the relationship of the presenting part to one of the pelvic quadrants that include the occiput (O), the chin (mentum [M]), the sacrum (Sa), or the acromion process (A). Position is indicated by an abbreviation of three letters. The first letter defines whether the landmark is pointing to the patient's right (R) or left (L).The middle letter denotes the fetal landmark. The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T). The nurse should document LMT. The other choices are an incorrect interpretation of the findings and use of the abbreviations.

19. 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

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 328-329 Feedback: Passageway focuses on the size and contour of the pregnant patient's pelvis. Passenger addresses the size, position, and presentation of the fetus. Powers determine if uterine factors for labor are adequate. Psychological outlook focuses on the pregnant patient's ability to view labor as a positive experience.

29. 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.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 349-350 Feedback: The fourth Leopold maneuver is only done if the fetus is in a cephalic presentation because it determines fetal attitude and degree of fetal extension into the pelvis. Angular bumps and nodules indicate the fetal knees, elbows, hands, and fingers. A round hard mass that moves freely is the fetal head.

25. 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.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 348-352 Feedback: If membranes rupture during labor, the fetal heart rate should be assessed immediately to be certain that the umbilical cord hasn't prolapsed and is now being compressed against the cervix by the fetal head. The patient does not need to be turned onto the left side. The amniotic fluid is tested for pH and not protein. Bearing down at this time could be dangerous, considering there is no way of knowing how much the cervix has dilated at the time of membrane rupture.

8. 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."

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 370 Feedback: An episiotomy widens the vaginal opening, decreasing pressure on the fetal head.

13. 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."

Ans: C Client Needs: Psychosocial Integrity Cognitive Level: Apply Page: 347-348 Feedback: Women with preset images of their child may have difficulty accepting an image other than the one they have created.

22. 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

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 354-355 Feedback: Hyperventilation occurs when the patient exhales more deeply than inhaling. As a result, extra carbon dioxide is blown off, and respiratory alkalosis results. This can occur during actual labor. The best way to manage hyperventilation is to prevent it by coaching the patient to end all breathing sessions with a long cleansing breath to help restore carbon dioxide balance. Difficulty using breathing techniques will not cause a risk for fluid volume deficit, anxiety related to stress of labor, or powerlessness related to duration of labor.

30. 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.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 369 Feedback: After placenta inspection, if the patient's uterus has not contracted firmly on its own, the primary care provider may prescribe oxytocin to help uterine contraction. Intravenous fluids and blood pressure measurement will not encourage uterine contract. It is premature to anticipate the patient needing a blood transfusion at this time.

6. 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

Ans: D Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Understand Page: 358 Feedback: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

11. 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.

Ans: D Client Needs: Psychosocial Integrity Cognitive Level: Apply Page: 342 Feedback: Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

24. 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.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 341 Feedback: During the active phase of labor, contractions grow so much stronger and last so much longer than they did in the latent phase. An appropriate outcome at this time would be that the patient keeps active and assumes whatever position is most comfortable during this time, except flat on the back (supine). An irresistible urge to push and nausea and vomiting may occur during the transition phase of labor.

20. 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

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 358 Feedback: Late decelerations are those that are delayed until 30 to 40 seconds after the onset of a contraction and continue beyond the end of a contraction. This is an ominous pattern in labor because it suggests uteroplacental insufficiency or decreased blood flow through the intervillous spaces of the uterus during uterine contractions. With uteroplacental insufficiency, the nurse will not observe on the monitor tracing variable unpredictable decelerations, an increase in fetal heart rate with contractions, or shallow decelerations at the beginning of contractions.

18. 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

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 339 Feedback: To determine the beginning of a contraction without a monitor, rest a hand on a woman's abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. This is the duration. Contractions are not timed by measuring the number of contractions in 5 minutes, the end of one contraction to the beginning of the next, or by using the interval between the acmes of two consecutive contractions.

26. 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.

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 363 Feedback: If a patient lies in a supine position and pushes during the second stage of labor, pressure of the uterus on the vena cava causes the blood pressure to drop, leading to hypotension. A side-lying position during the second stage of labor can help avoid such a problem. Fluids would be indicated if the patient is having epidural anesthesia.

27. 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

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 366 Feedback: Pushing is usually best done from a semi-Fowler's position with legs raised against the abdomen. Lying on the side or supine in the lithotomy position are not positions conducive to successful delivery. The patient should be coached to not hold the breath during a contraction or pushing because this could increase intrathoracic pressure, which could interfere with blood supply to the uterus.