Exam 2 - Chapter 19

Question 1

The nurse recognizes that a woman is in true labor when she states:
a.
“I passed some thick, pink mucus when I urinated this morning.”
b.
“My bag of waters just broke.”
c.
“The contractions in my uterus are getting stronger and closer together.”
d.
“My baby dropped, and I have to urinate more frequently now.”

Answer 1

C - Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.
Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor.
Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor.
The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.

Question 2

When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:
a.
Tell the woman to stay home until her membranes rupture
b.
Emphasize that food and fluid intake should stop
c.
Arrange for the woman to come to the hospital for labor evaluation
d.
Ask the woman to describe why she believes she is in labor

Answer 2

D - Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data.
The initial nursing activity should be to gather data about the woman’s status. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular.
The initial nursing activity should be to gather data about the woman’s status. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.
Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.

Question 3

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for \_\_\_\_\_ has increased.
a.
Intrauterine infection
b.
Hemorrhage
c.
Precipitous labor
d.
Supine hypotension

Answer 3

A - When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis.
Rupture of membranes (ROM) is not associated with fetal or maternal bleeding.
Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor.
ROM has no correlation with supine hypotension.

Question 4

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg, and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. Based on this information, the nurse should:
a.
Notify the woman’s primary health care provider immediately
b.
Prepare to administer an oxytocic to stimulate uterine activity
c.
Document the findings because they reflect the expected contraction pattern for the active phase of labor
d.
Prepare the woman for the onset of the second stage of labor

Answer 4

C - The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. Additionally the nurse documents these findings in the client’s medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor.
Nothing indicates a need to notify the primary health care provider at this time.
Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor.

Question 5

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.

Answer 5

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.

Question 6

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective is:
a.
Dilation of the cervix
b.
Descent of the fetus
c.
Rupture of the amniotic membranes
d.
Increase in bloody show

Answer 6

A - The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor.
Descent of the fetus, or engagement, may occur before labor.
Rupture of membranes may occur with or without the presence of labor.
Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.

Question 7

The nurse who performs vaginal examinations to assess a woman’s progress in labor should:
a.
Perform an examination at least once every hour during the active phase of labor
b.
Perform the examination with the woman in the supine position
c.
Wear two clean gloves for each examination
d.
Discuss the findings with the woman and her partner

Answer 7

D - The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider.
A vaginal examination should be performed only when indicated by the status of the woman and her fetus.
The woman should be positioned so as to avoid supine hypotension.
The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.

Question 8

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse’s initial response is 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

Answer 8

D - The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented.
Rupture of membranes (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.

Question 9

The nurse should assist the laboring woman into a hands-and-knees position when:
a.
The occiput of the fetus is in a posterior position
b.
The fetus is at or above the ischial spines
c.
The fetus is in a vertex presentation
d.
The membranes rupture

Answer 9

A - The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position.
Many women experience the irresistible urge to push when the fetus is at the level of the ischial spines. In some cases this occurs before the woman is fully dilated. The woman should be instructed not to push until complete cervical dilation has occurred.
No one position is correct for childbirth. The two most common positions assumed by women are the sitting and side-lying positions.
The woman may be encouraged into a hands-and-knees position if the umbilical cord prolapsed when the membranes ruptured.

Question 10

A nulliparous woman who has just begun the second stage of her labor most likely:
a.
Experiences a strong urge to bear down
b.
Shows perineal bulging
c.
Feels tired yet relieved that the worst is over
d.
Shows an increase in bright red bloody show

Answer 10

C - Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because “the worst is over.” The woman may be very quiet during this phase.
During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions.
Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage.
An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

Question 11

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

Answer 11

C - During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down.
Rupture of membranes (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 part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm dilation.

Question 12

Through vaginal examination, the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3½ to 4 minutes. The nurse reports this as:
a.
First stage, latent phase
b.
First stage, active phase
c.
First stage, transition phase
d.
Second stage, latent phase

Answer 12

B - This maternal progress indicates that the woman is in the active phase of the first stage of labor.
During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes.
During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes.
During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of “laboring down.”

Question 13

The most critical nursing action in caring for the newborn immediately after birth is:
a.
Keeping the 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

Answer 13

A - The care given immediately after the birth focuses on assessing and stabilizing the newborn.
Although fostering parent-newborn 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 care given immediately after birth focuses on assessing and stabilizing the newborn. The nursing activities are (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering 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 partner or the mother the infant.

Question 14

The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to:
a.
Relieve pain
b.
Stimulate uterine contraction
c.
Prevent infection
d.
Facilitate rest and relaxation

Answer 14

B - Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor.
Oxytocics are not used to treat pain.
Oxytocics do not prevent infection.
Oxytocics do not facilitate rest and relaxation.

Question 15

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
b.
Active: moderate, regular contractions; 4 to 7 cm dilation
c.
Lull: no contractions; dilation stable
d.
Transition: very strong but irregular contractions; 8 to 10 cm dilation

Answer 15

B - The active phase is characterized by moderate, regular contractions, 4 to 7 cm dilation, and a duration of 3 to 6 hours.
The latent phase is characterized by mild to moderate, irregular contractions, dilation up to 3 cm, brownish to pale pink mucus, and a duration of 6 to 8 hours.
No official “lull” phase exists in the first stage.
The transition phase is characterized by strong to very strong, regular contractions, 8 to 10 cm dilation, and a duration of 20 to 40 minutes.

Question 16

With regard to the procedures and criteria for admitting a woman to the hospital labor unit, nurses should be aware that:
a.
She 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.
She can have only her male partner or predesignated doula with her at assessment
c.
Her weight gain is calculated to determine whether she is at greater risk for complications
d.
The nurse should listen politely to the woman’s previous birthing experiences but should keep in mind that each birth is a unique experience

Answer 16

C - Increasing numbers of women are overweight or obese. Excessive size can make nursing care during labor and birth more difficult and places the woman at risk for complications such as operative birth, infection, and blood clots.
According to EMTALA, a woman is entitled to active labor care and is presumed to be in “true” labor until a qualified health care provider certifies otherwise.
A woman may have anyone she wishes present for her support.
The details of previous birthing experiences are important. Not only the mechanics of labor and the outcome but also the woman’s perceptions can influence her present attitude.

Question 17

As part of the physical examination component of assessment, Leopold maneuvers are used to help identify all of the following except:
a.
The gender of the fetus
b.
The number of fetuses
c.
The fetal lie and attitude
d.
The degree of the presenting part’s descent into the pelvis

Answer 17

A - Leopold maneuvers help identify the number of fetuses, the fetal lie and attitude, and the presenting part’s degree of descent into the pelvis. The gender of the fetus cannot be determined by performing Leopold maneuvers.
Leopold maneuvers help identify the number of fetuses.
Leopold maneuvers assist the nurse in determining the fetal lie and attitude.
Leopold maneuvers can be used to ascertain the presenting part’s degree of descent into the pelvis.

Question 18

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart rate (FHR) 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

Answer 18

C - Nurses should be prepared for the shift.
The PMI of the FHR usually is directly over the fetal back.
In a vertex position, it is heard below the mother’s umbilicus.
In a breech position, it is heard above the mother’s umbilicus

Question 19

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.
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

Answer 19

A - Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration.
Routine IV fluids during labor are unlikely to be beneficial and may be harmful.
Routine use of an enema is at best ineffective and may be harmful.
Having the urge to defecate followed by the birth of her fetus is true for a multiparous woman but not for a first-timer.

Question 20

Nurses alert to signs of the onset of the second stage of labor can be certain that 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 tries to bear down

Answer 20

B - The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.
Sudden vomiting is a suggestion of second-stage labor; however, the only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.
Bloody show increases during the second stage of labor; however, the inability to feel the cervix is an objective sign that the second stage has begun.
The urge to bear down is a suggestion of second-stage labor. The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.

Question 21

A means of controlling the birth of the fetal head with a vertex presentation is:
a.
The Ritgen maneuver
b.
Fundal pressure
c.
The lithotomy position
d.
The De Lee apparatus

Answer 21

A - The Ritgen maneuver extends the head during the actual birth and protects the perineum.
Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth.
The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider.
The De Lee apparatus is used to suction fluid from the infant’s mouth.

Question 22

Which collection of risk factors will most likely 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

Answer 22

D - Reddish-haired women have tissue that is less distensible than darker-skinned women and so may have less efficient healing. First-time mothers are also more at risk, especially with breech births, long second-stage labors, or rapid labors in which there is insufficient time for the perineum to stretch. The rate of episiotomies is higher when obstetricians rather than midwives attend births.
This woman is at low risk for either damaging lacerations or an episiotomy. The client is multiparous, has dark skin, and is being attended by a midwife (who is less likely to perform an episiotomy).
Reddish-haired women have tissue that is less distensible than that of darker-skinned women. This puts the client at increased risk for lacerations; however, she has had two previous deliveries, which result in a lower likelihood of an episiotomy.
The fact that this woman is experiencing a prolonged labor might increase her risk for lacerations. Fortunately she is dark skinned, which indicates that her tissue is more distensible than that of fair-skinned women and therefore less susceptible to injury.

Question 23

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 appears before the shiny fetal surface
d.
The major risk for women during the third stage is a rapid heart rate

Answer 23

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 hemorrhage.

Question 24

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-oz boy after augmentation of labor with oxytocin (Pitocin). She puts on her call light and asks for her nurse right away, stating “I’m bleeding a lot.” The most likely cause of postpartum hemorrhage in this woman is:
a.
Retained placental fragments
b.
Unrepaired vaginal lacerations
c.
Uterine atony
d.
Puerperal infection

Answer 24

C - This woman gave birth to a macrosomic infant after oxytocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony.
Although retained placental fragments may cause postpartum hemorrhage, this typically is detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman.
Although unrepaired vaginal lacerations may cause bleeding, they typically occur in the period immediately after birth.
Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically is detected after 24 hours postpartum.

Question 25

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:
a.
Has recovered from epidural or spinal anesthesia
b.
Has hidden bleeding underneath her
c.
Has regained some flexibility
d.
Is a candidate to go home after 6 hours

Answer 25

A - If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia.
It is always important to assess the client for bleeding beneath her buttocks prior to discharge from the recovery room; however, she should be rolled to her side for this assessment.
The nurse is not required to assess the woman for flexibility.
This assessment is performed in order to evaluate if the client has recovered from spinal anesthesia, not to determine if she is a candidate for early discharge.

Question 26

A woman who has a history of sexual abuse may have a number of traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care?
a.
Tell the client to relax and that it won’t hurt much
b.
Limit the number of procedures that invade her body
c.
Reassure the client that as the nurse you know what is best
d.
Allow unlimited care providers to be with the client

Answer 26

B - The number of invasive procedures such as vaginal examinations, internal monitoring, and IV therapy should be limited as much as possible.
The nurse should always avoid words and phrases that may result in the client’s recalling the phrases of her abuser (i.e., “Relax, this won’t hurt” or “Just open your legs”).
The woman’s sense of control should be maintained at all times. The nurse should explain procedures at the client’s pace and wait for permission to proceed.
Protecting the client’s environment by providing privacy and limiting the number of staff who observe the client will help to make her feel safe.

Question 27

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 practices and learn to incorporate them into a mutually agreed-upon 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 should anticipate that a woman from which country will have the baby’s father in attendance?
a.
Mexico
b.
China
c.
Iran
d.
India

Answer 27

A - A woman from Mexico may be stoic about discomfort until the second stage, at which time she will request pain relief. Fathers and female relatives are usually in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well.
In China fathers are usually not present. The side-lying position is preferred for labor and birth because it is believed that this will reduce trauma to the infant. The client has a stoic response to pain.
In Iran the father will not be present. Female support persons and female health care providers are preferred. For many, a male caregiver is unacceptable.
In India the father is usually not present, but female relatives are usually present. Natural childbirth methods are preferred.

Question 28

Emergency conditions during labor that require immediate nursing intervention can arise with startling speed. Examples of such emergencies include (choose all that apply):
a.
Nonreassuring or abnormal fetal heart rate (FHR) pattern
b.
Inadequate uterine relaxation
c.
Vaginal bleeding
d.
Infection
e.
Prolapse of the cord

Answer 28

A,B,C,D,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.

Question 29

Women who have participated in childbirth education classes often bring a birth plan with them to the hospital. This document includes the couple’s preference related to (choose all that apply):
a.
Presence of companions
b.
Clothing to be worn
c.
Care and handling of the newborn
d.
Medical interventions
e.
Environmental modifications

Answer 29

A,B,C,D,E - 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. Couples can visit www.childbirth.org for an interactive birth plan to assist them in preparing for their birth.