Evolve Maternity Nursing Chap 9-12

Question 1

A primigravida asks the nurse about what signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe:

a. Weight gain of 1 to 3 pounds.
b. Quickening.
c. Fatigue and lethargy.
d. Bloody show.

Answer 1

d. Bloody show.

Passage of the mucous plug (operculum), also termed pink/bloody show, occurs as the cervix ripens.

Question 2

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be:

a. Progressive uterine contractions.
b. Lightening.
c. Rupture of membranes.
d. Passage of the mucous plug (operculum).

Answer 2

a. Progressive uterine contractions.

Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor.

Question 3

On completion of a vaginal examination of a laboring woman, the nurse records the following: 50%, 6 cm, –1. What is a correct interpretation of this data?

a. The fetal presenting part is 1 cm above the ischial spines.
b. Effacement is 4 cm from completion.
c. Dilation is 50% completed.
d. The fetus has achieved passage through the ischial spines.

Answer 3

a. The fetal presenting part is 1 cm above the ischial spines.

Station of –1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet.

Question 4

What position would be least effective when the intent is to use gravity to assist in fetal descent?

a. Lithotomy
b. Kneeling
c. Sitting
d. Walking

Answer 4

a. Lithotomy

The predominant position in the United States for physician-attended births is the lithotomy position, which requires a woman to be in a reclined position with her legs in stirrups. Gravity has little effect in this position.

Question 5

With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that:

a. The fetal attitude describes the angle at which the fetus exits the uterus.
b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother.
c. The normal attitude of the fetus is called general flexion.
d. The transverse lie is preferred for vaginal birth.

Answer 5

c. The normal attitude of the fetus is called general flexion.

The normal attitude of the fetus is general flexion.

Question 6

Which description and percentage of occurrence of a basic pelvis type in women is correct?

a. Gynecoid: classic female; heart shaped; 75%
b. Android: resembling the male; wider oval; 15%
c. Anthropoid: resembling the ape; narrower; 10%
d. Platypelloid: flattened, wide, shallow; 3%

Answer 6

d. Platypelloid: flattened, wide, shallow; 3%

A platypelloid pelvis is flattened, wide, and shallow; about 3% of women have this shape.

Question 7

The slight overlapping of cranial bones, or shaping of the fetal head, that occurs during labor is called:

a. Lightening.
b. Molding.
c. Ferguson reflex.
d. Valsalva maneuver.

Answer 7

b. Molding.

Molding, the shaping of the fetal head during labor, also permits adaptation to various diameters of the maternal pelvis.

Question 8

What factors influence cervical dilation? Choose all that apply.

a. Strong uterine contractions
b. The force of the presenting fetal part against the cervix
c. The size of the female
d. The pressure applied by the amniotic sac
e. Scarring of the cervix

Answer 8

a. Strong uterine contractions
b. The force of the presenting fetal part against the cervix
d. The pressure applied by the amniotic sac
e. Scarring of the cervix

Question 9

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse’s immediate response would be to:

a. Encourage the woman to breathe more slowly.
b. Help the woman breathe into a paper bag.
c. Turn the woman on her side.
d. Administer a sedative.

Answer 9

b. Help the woman breathe into a paper bag.

The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her exhaled air would increase the carbon dioxide level.

Question 10

A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?

a. Meperidine (Demerol)
b. Promethazine (Phenergan)
c. Butorphanol tartrate (Stadol)
d. Nalbuphine (Nubain)

Answer 10

a. Meperidine (Demerol)

Meperidine used to be the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Other medication options with fewer side effects are now available for use during labor.

Question 11

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:

a. Counterpressure against the sacrum.
b. Pant-blow (breaths and puffs) breathing techniques.
c. Effleurage.
d. Conscious relaxation or guided imagery.

Answer 11

a. Counterpressure against the sacrum.

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back.

Question 12

Nurses should be aware of the differences experience can make in how labor pain is perceived, such as:

a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.
b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor.
c. Women with a history of substance abuse experience more pain during labor.
d. Multiparous women have more fatigue from labor and therefore experience more pain.

Answer 12

a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple.

Question 13

With regard to breathing techniques used by a woman during labor, maternity nurses should be aware that:

a. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.
b. By the time labor has begun, it is too late for instruction in breathing and relaxation.
c. Controlled breathing techniques are most difficult to adhere to near the end of the second stage of labor.
d. The patterned-paced breathing technique can help prevent hyperventilation.

Answer 13

a. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

First-stage breathing techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity.

Question 14

With regard to systemic analgesics administered during labor, nurses should be aware that:

a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier.
b. Effects on the fetus and newborn can include decreased alertness and delayed sucking.
c. Intramuscular administration (IM) is preferred over intravenous (IV) administration.
d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

Answer 14

b. Effects on the fetus and newborn can include decreased alertness and delayed sucking.

Effects depend on the specific drug given, the dosage, and the timing.

Question 15

With regard to spinal and epidural (block) anesthesia, nurses should know that:

a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births.
b. A high incidence of after-birth headache is seen with spinal blocks.
c. Epidural blocks allow the woman to move freely.
d. Spinal and epidural blocks are never used together.

Answer 15

b. A high incidence of after-birth headache is seen with spinal blocks.

A high incidence of after-birth headache can occur; headaches may be prevented or mitigated to some degree by a number of methods.

Question 16

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the patient’s blood pressure if hypotension occurs? Choose all that apply.

a. Place the woman in a supine position.
b. Place the woman in a lateral position.
c. Increase intravenous (IV) fluids.
d. Administer oxygen.
e. Perform a vaginal examination.

Answer 16

b. Place the woman in a lateral position.
c. Increase intravenous (IV) fluids.
d. Administer oxygen.

Question 17

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to:

a. Maternal hyperthyroidism.
b. Initiation of epidural anesthesia that resulted in maternal hypotension.
c. Maternal infection accompanied by fever.
d. Alteration in maternal position from semirecumbent to lateral.

Answer 17

b. Initiation of epidural anesthesia that resulted in maternal hypotension.

Fetal bradycardia is the pattern described; it results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure.

Question 18

On review of a fetal monitor tracing, the nurse notes that for several contractions the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should:

a. Describe the finding in the nurse’s notes.
b. Reposition the woman onto her side.
c. Call the physician for instructions.
d. Administer oxygen at 8 to 10 L/min with a tight face mask.

Answer 18

a. Describe the finding in the nurse’s notes.

An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix.

Question 19

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?

a. FHR does not change as a result of fetal activity.
b. Average baseline rate ranges between 100 and 140 beats/min.
c. Mild late deceleration patterns occur with some contractions.
d. Variability averages between 6 to 10 beats/min.

Answer 19

d. Variability averages between 6 to 10 beats/min.

Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.

Question 20

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse’s immediate action would be to:

a. Change the woman’s position.
b. Stop the Pitocin.
c. Elevate the woman’s legs.
d. Administer oxygen via a tight mask at 8 to 10 L/min.

Answer 20

b. Stop the Pitocin.

Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion because Pitocin is an oxytocic that stimulates the uterus to contract.

Question 21

The nurse providing care for the laboring woman should understand that accelerations with fetal movement:

a. Are reassuring.
b. Are caused by umbilical cord compression.
c. Warrant close observation.
d. Are caused by uteroplacental insufficiency.

Answer 21

a. Are reassuring.

Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being.

Question 22

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:

a. The examiner’s hand should be placed over the fundus before, during, and after contractions.
b. The frequency and duration of contractions is measured in seconds for consistency.
c. Contraction intensity is given a judgment number of 1 to 7 by the nurse and patient together.
d. The resting tone between contractions is described as either placid or turbulent.

Answer 22

a. The examiner’s hand should be placed over the fundus before, during, and after contractions.

The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed.

Question 23

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:

a. Change in position.
b. Oxytocin administration.
c. Regional anesthesia.
d. Intravenous analgesic.

Answer 23

a. Change in position.

Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman’s heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position.

Question 24

Fetal well-being during labor is assessed by:

a. The response of the fetal heart rate (FHR) to uterine contractions (UCs).
b. Maternal pain control.
c. Accelerations in the FHR.
d. An FHR above 110 beats/min.

Answer 24

a. The response of the fetal heart rate (FHR) to uterine contractions (UCs).

Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement.

Question 25

Which correctly matches the type of deceleration with its likely cause? a. Early deceleration—umbilical cord compression b. Late deceleration—uteroplacental inefficiency c. Variable deceleration—head compression d. Prolonged deceleration—cause unknown

Answer 25

b. Late deceleration—uteroplacental inefficiency Late deceleration is caused by uteroplacental inefficiency.

Question 26

The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: a. Altered cerebral blood flow. b. Fetal hypoxemia. c. Umbilical cord compression. d. Fetal sleep cycles.

Answer 26

d. Fetal sleep cycles. A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes.

Question 27

You are evaluating the fetal monitor tracing of your patient, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take? a. Scream for help. b. Insert a Foley catheter. c. Start pitocin. d. Notify the care provider immediately.

Answer 27

d. Notify the care provider immediately. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately.

Question 28

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one’s breath with a closed glottis and tightening the abdominal muscles. During the second stage of labor, when the woman is ready to push, this is considered the optimal method to enhance movement of the fetus down the birth canal. a. True b. False

Answer 28

b. False This process stimulates the parasympathetic division of the autonomic nervous system and will produce a vagal response (decrease in heart rate and blood pressure). An alternative method would include instructing the woman to perform open-mouth and open-glottis breathing and pushing.

Question 29

Which characteristic is associated with false labor contractions? a. Painful b. Decrease in intensity with ambulation c. Regular pattern of frequency established d. Progressive in terms of intensity and duration

Answer 29

B. Decrease in intensity with ambulation True labor contractions are painful; false labor contractions typically are not. Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.

Question 30

A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent’s class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? a. “My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK.” b. “We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor.” c. “We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born.” d. “We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage.”

Answer 30

D. "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage." Having someone other than the husband as coach is an acceptable request during labor and delivery. Using Lamaze techniques during labor and delivery is an acceptable part of a birth plan. Using a birthing room during labor and delivery and having the husband come in right after the birth is an acceptable part of a birth plan. Because monitoring is essential to assess fetal well-being, whether to use monitoring is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and labor is progressing normally.

Question 31

When performing vaginal examinations on laboring women, the nurse should be guided by what principle? a. Cleanse the vulva and perineum before and after the examination as needed. b. Wear a clean glove lubricated with tap water to reduce discomfort. c. Perform the examination every hour during the active phase of the first stage of labor. d. Perform the examination immediately if active bleeding is present.

Answer 31

A. Cleanse the vulva and perineum before and after the examination as needed. Cleansing will reduce the possibility of secretions and microorganisms ascending into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to prevent infection. Vaginal examinations should only be performed as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

Question 32

Following rupture of membranes, a prolapse of the cord was noted on vaginal examination. A recommended action to alleviate cord compression would be to: a. Place woman in a supine position and elevate legs from the hips. b. Insert a Foley catheter to keep the bladder empty. c. Keep the protruding cord moist with warm sterile normal saline compresses. d. Attempt to reinsert the cord.

Answer 32

C. Keep the protruding cord moist with warm sterile normal saline compresses. The hips should be elevated using a Sims or knee-chest position when cord prolapse is detected. A distended bladder has a beneficial effect; it elevates the presenting part and inhibits uterine contractions, so a catheter insertion is not recommended. It is advised to keep the protruding cord moist with sterile saline until further help arrives. Never attempt to reinsert the cord because it may be injured in the process.

Question 33

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 33

C. "The contractions in my uterus are getting stronger and closer together." 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. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing 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 34

What is an expected characteristic of amniotic fluid? a. Deep yellow color b. Pale, straw color with small white particles c. Acidic result on a Nitrazine test d. Absence of ferning

Answer 34

B. Pale, straw color with small white particles Yellow-stained fluid may indicate fetal hypoxia up to 36 hours before rupture of membranes, fetal hemolytic disease, or intrauterine infection. Amniotic fluid normally is a pale, straw-colored fluid that may contain white flecks of vernix. Amniotic fluid produces an alkaline result on a Nitrazine test. The presence of ferning is a positive indication of amniotic fluid.

Question 35

Which action would be correct when palpation is being 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 of the contraction by pressing the fingertips into the uterine fundus, d. Assess uterine contractions every 30 minutes throughout the first stage of labor.

Answer 35

C. Evaluate the intensity of the contraction by pressing the fingertips into the uterine fundus, 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. The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently.

Question 36

The nurse knows that the second stage of labor, the descent phase, has begun when the: a. Amniotic membranes rupture. b. Cervix cannot be felt during a vaginal examination. c. Woman experiences a strong urge to bear down. d. Presenting part is below the ischial spines.

Answer 36

C. Woman experiences a strong urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. 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 37

Nurses can help their patients by keeping them informed about the distinctive stages of labor. Which description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours

Answer 37

B. Active: Moderate, regular contractions; 4- to 7-cm dilation; 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. The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 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 38

In documenting labor experiences, nurses should know that a uterine contraction is described according to all of these characteristics except: a. Frequency (how often contractions occur). b. Intensity (the strength of the contraction at its peak). c. Resting tone (the tension in the uterine muscle). d. Appearance (shape and height).

Answer 38

D. Appearance (shape and height). Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not a documented characteristic of contractions. Uterine contractions are described in terms of frequency, intensity, duration, and resting tone.

Question 39

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

Answer 39

B. An expectant or active approach to managing this stage of labor reduces the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Active management facilitates placental separation and expulsion, reducing the risk of complications. 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 40

A ____________________-degree perineal laceration continues through the anal sphincter muscle.

Answer 40

- third - Perineal lacerations occur as the fetal head is being born. The extent of the laceration is defined in terms of its depth. A first-degree laceration extends through the skin and superficial structures. A second-degree laceration extends through the muscles of the perineal body. A fourth-degree laceration involves the anterior rectal wall.