Chapter 18 Flashcards
The nurse recognizes that a woman is in true labour when she states which of the following?
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.”
C
The nurse teaches a pregnant woman about the characteristics of true labour contractions. The nurse knows that the woman has understood the teaching when she states which of the following about true labour contractions?
a.
“They subside when I walk around.”
b.
“They cause discomfort over the top of my uterus.”
c.
“They continue and get stronger even if I relax and take a shower.”
d.
“They remain irregular but become stronger.”
C
When a nulliparous woman telephones the hospital to report that she is in labour, what should the nurse do, initially?
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 labour evaluation.
d.
Ask the woman to describe why she believes she is in labour.
D
What is an expected characteristic of amniotic fluid? a. Deep yellow colour b. Pale, straw colour with small white particles c. Acidic result on a Nitrazine test d. Absence of ferning
B
When planning care for a labouring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for which of the following has increased? a. Intrauterine infection b. Hemorrhage c. Precipitous labour d. Supine hypotension
A
The uterine contractions of a woman early in the active phase of labour 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. On the basis of this information, what should the nurse do?
a.
Notify the woman’s primary health care provider immediately.
b.
Prepare to administer oxytocin to stimulate uterine activity.
c.
Document the findings, as they are considered normal for this phase.
d.
Prepare the woman for onset of the second stage of labour.
C
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 labour.
C
When assessing a woman in the first stage of labour, the nurse recognizes that which of the following is the most conclusive sign that uterine contractions are effective? a. Dilation of the cervix b. Descent of the fetus c. Rupture of the amniotic membranes d. Increase in bloody show
A
The nurse who performs vaginal examinations to assess a woman’s progress in labour should do which of the following?
a.
Perform an examination at least once every hour during the active phase of labour.
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.
D
A multiparous woman has been in labour for 8 hours. Her membranes have just ruptured. What is the nurse’s initial response?
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.
D
What would the nurse expect from a nulliparous woman who has just begun the second stage of her labour?
a.
The woman will experience a strong urge to bear down.
b.
The woman will show perineal bulging.
c.
The woman will feel tired yet relieved that the first stage is over.
d.
The woman will show an increase in bright red bloody show.
C
Which finding indicates to the nurse that the second stage of labour, the descent phase, has begun?
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.
C
When managing the care of a woman in the second stage of labour, the nurse uses various measures to enhance the progress of fetal descent. Which interventions would be appropriate at this time?
a.
Encourage the woman to try various upright positions, including squatting and standing.
b.
Tell the woman to start pushing as soon as her cervix is fully dilated.
c.
Continue an epidural anaesthetic so that pain is reduced and the woman can relax.
d.
Coach the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.
A
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. How should the nurse document these findings? a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage, latent phase
B
What is the priority nursing action in caring for the newborn immediately after birth? a. Keep the newborn’s airway clear. b. Foster parent–newborn attachment. c. Dry the newborn and wrap the infant in a blanket. d. Administer eye drops and vitamin K.
A
