Maternity: Chapter 14 Practice Questions
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?
assess amount of cervical dilation (If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation.)
The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate what information in the teaching about measures to help to decrease the requests for pain medication?
continuous support through the labor process helps decrease need for pain medication
The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed?
determining the lie of the fetus determining the presentation of the fetus determining the position of the fetus
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?
placing a wedge under the hips (Due to the lithotomy position, the nursing action of placing a wedge under the hips is correct to avoid supine hypotension.)
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
turn her or ask her to turn to her side (The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.)
Which assessment findings indicate a distressed fetus?
absent accelerations late deceleration patterns persistent bradycardia
Which intervention would be least effective in caring for a woman who is in the transition phase of labor?
encouraging the woman to ambulate (Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult.)
The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first?
feel for the fetal buttocks or head while palpating the abdomen
As a woman enters the second stage of labor, which would the nurse expect to assess?
feelings of being frightened by the change in contractions
The client may spend the latent phase of the first stage of labor at home unless which occurs?
the client experiences a rupture of membranes
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is _________.
7.15 or less (In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.)
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. What nursing intervention should the nurse perform next?
administration of oxygen by mask (The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus.)
The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as _____.
baseline FHR
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as _______.
effleurage
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
every 15 minutes (During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.)
A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?
"Our baby will come out face first."
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?
10:30 am (Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns.)
The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?
acupressure
A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?
naloxone
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?
"It distracts your brain from the sensations of pain." (method of distraction or another method of keeping sensory input from reaching the cortex of the brain)
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. What would be the most appropriate response by the nurse?
"The injection is given in the space outside of the spinal cord." (An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.)
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
inability to push (If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system.)
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
lower left quadrant (The best position to auscultate fetal heart tones in on the fetus back.)
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?
this may prolong labor and increase complications
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine (commonly used opioid during labor and birth for pain management)
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?
clear to straw-colored fluid (normal color of amniotic fluid)
The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?
client priorities and preferences are incorporated into the plan
The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time?
have the woman change her position
General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?
neonatal depression is possible
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending?
palpate the area just above the symphysis pubis (Palpate just above the symphysis pubis to determine if the infant is engaged and to determine the presenting part of the infant; it is possible for infants to rotate and change position during labor.)
