Unit I-Labor and Delivery

Question 1

A new mother asks the nurse when the “soft spot” on her son’s head will go away. The
nurse’s answer is based on the knowledge that the anterior fontanel closes after birth by _____
months.
a. 2
b. 8
c. 12
d. 18

Answer 1

ANS: D

The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.

Question 2

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body
parts to one another is called fetal:
a. lie.
b. presentation.
c. attitude.
d. position.

Answer 2

ANS: C
Attitude is the relation of the fetal body parts to one another. Lie is the relation of the long axis
(spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the
fetus that enters the pelvic inlet first and leads through the birth canal during labor at term.
Position is the relation of the presenting part to the four quadrants of the mother’s pelvis.

Question 3

When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable
fetal part in the fundal portion of the uterus and a long, smooth surface in the mother’s right
side close to midline. What is the likely position of the fetus?
a. ROA
b. LSP
c. RSA
d. LOA

Answer 3

ANS:C
The fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the
presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. The
first letter indicates the presenting part in either the right or left side of the maternal pelvis.
The second letter indicates the anatomic presenting part of the fetus. The third letter stands for
the location of the presenting part in relation to the anterior, posterior, or transverse portion of
the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus
would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the
presenting part in the maternal pelvis. Palpation of the fetal spine along the mother’s right side
denotes the location of the presenting part in the mother’s pelvis. The ability to palpate the
fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis.

Question 4

The nurse has received report regarding her patient in labor. The woman’s last vaginal
examination was recorded as 3 cm, 30%, and –2. The nurse’s interpretation of this assessment
is that:
a. the cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above
the ischial spines.
b. the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above
the ischial spines.
c. the cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below
the ischial spines.
d. the cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below
the ischial spines.

Answer 4

ANS: B
The correct description of the vaginal examination for this woman in labor is the cervix is 3
cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The
sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of
cervical dilation, and the relationship of the presenting part to the ischial spines (either above
or below).

Question 5

To care for a laboring woman adequately, the nurse understands that the \_\_\_\_\_\_\_\_\_\_ stage of
labor varies the most in length?
a. first
b. second
c. third
d. fourth

Answer 5

ANS:A
The first stage of labor is considered to last from the onset of regular uterine contractions to
full dilation of the cervix. The first stage is much longer than the second and third stages
combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The
second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus.
The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous
woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered.
This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor,
recovery, lasts about 2 hours after delivery of the placenta.

Question 6

The nurse would expect which maternal cardiovascular finding during labor?

a. Increased cardiac output
b. Decreased pulse rate
c. Decreased white blood cell (WBC) count
d. Decreased blood pressure

Answer 6

ANS: A
During each contraction, 400 mL of blood is emptied from the uterus into the maternal
vascular system. This increases cardiac output by about 51% above baseline pregnancy values
at term. The heart rate increases slightly during labor. The WBC count can increase during
labor. During the first stage of labor, uterine contractions cause systolic readings to increase
by about 10 mm Hg. During the second stage, contractions may cause systolic pressures to
increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg.

Question 7

The factors that affect the process of labor and birth, known commonly as the five Ps, include
all except:
a. passenger.
b. passageway.
c. powers.
d. pressure.

Answer 7

ANS: D
The five Ps are passenger (fetus and placenta), passageway (birth canal), powers
(contractions), position of the mother, and psychologic response

Question 8

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

a. lightening.
b. molding.
c. Ferguson reflex.
d. Valsalva maneuver.

Answer 8

ANS:B
Fetal head formation is called molding. Molding also permits adaptation to various diameters
of the maternal pelvis. Lightening is the mother’s sensation of decreased abdominal
distention, which usually occurs the week before labor. The Ferguson reflex is the contraction
urge of the uterus after stimulation of the cervix. The Valsalva maneuver describes conscious
pushing during the second stage of labor.

Question 9

Which presentation is described accurately in terms of both presenting part and frequency of
occurrence?
a. Cephalic: occiput; at least 95%
b. Breech: sacrum; 10% to 15%
c. Shoulder: scapula; 10% to 15%
d. Cephalic: cranial; 80% to 85%

Answer 9

ANS: A
In cephalic presentations (head first), the presenting part is the occiput; this occurs in 96% of
births. In a breech birth, the sacrum emerges first; this occurs in about 3% of births. In
shoulder presentations, the scapula emerges first; this occurs in only 1% of births.

Question 10

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 10

ANS: C
The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal
body parts to one another. The horizontal lie is perpendicular to the mother; in the
longitudinal (or vertical) lie the long axes of the fetus and the mother are parallel. Vaginal
birth cannot occur if the fetus stays in a transverse lie.

Question 11

As relates to fetal positioning during labor, nurses should be aware that:
a. position is a measure of the degree of descent of the presenting part of the fetus
through the birth canal.
b. birth is imminent when the presenting part is at +4 to +5 cm below the spine.
c. the largest transverse diameter of the presenting part is the suboccipitobregmatic
diameter.
d. engagement is the term used to describe the beginning of labor.

Answer 11

ANS:B
The station of the presenting part should be noted at the beginning of labor so that the rate of
descent can be determined. Position is the relation of the presenting part of the fetus to the
four quadrants of the mother’s pelvis; station is the measure of degree of descent. The largest
diameter usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest,
although one of the most critical. Engagement often occurs in the weeks just before labor in
nulliparas and before or during labor in multiparas.

Question 12

Which basic type of pelvis includes the correct description and percentage of occurrence in
women?
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 12

ANS: D
A platypelloid pelvis is flattened, wide, and shallow; about 3% of women have this shape. The
gynecoid shape is the classical female shape, slightly ovoid and rounded; about 50% of
women have this shape. An android, or male-like, pelvis is heart shaped; about 23% of
women have this shape. An anthropoid, or ape-like, pelvis is oval and wider; about 24% of
women have this shape.

Question 13

In relation to primary and secondary powers, the maternity nurse comprehends that:
a. primary powers are responsible for effacement and dilation of the cervix.
b. effacement generally is well ahead of dilation in women giving birth for the first
time; they are closer together in subsequent pregnancies.
c. scarring of the cervix caused by a previous infection or surgery may make the
delivery a bit more painful, but it should not slow or inhibit dilation.
d. pushing in the second stage of labor is more effective if the woman can breathe
deeply and control some of her involuntary needs to push, as the nurse directs

Answer 13

ANS: A
The primary powers are responsible for dilation and effacement; secondary powers are
concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in
first-timers; they are closer together in subsequent pregnancies. Scarring of the cervix may
slow dilation. Pushing is more effective and less fatiguing when the woman begins to push
only after she has the urge to do so.

Question 14

While providing care to a patient in active labor, the nurse should instruct the woman that:

a. the supine position commonly used in the United States increases blood flow.
b. the “all fours” position, on her hands and knees, is hard on her back.
c. frequent changes in position will help relieve her fatigue and increase her comfort.
d. in a sitting or squatting position, her abdominal muscles will have to work harder.

Answer 14

ANS: C
Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood
flow can be compromised in the supine position; any upright position benefits cardiac output.
The “all fours” position is used to relieve backache in certain situations. In a sitting or
squatting position, the abdominal muscles work in greater harmony with uterine contractions.

Question 15

Which description of the four stages of labor is correct for both definition and duration?
a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to
20 hours
b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours
c. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes
(first-timer)
d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

Answer 15

ANS: A
Full dilation may occur in less than 1 hour, but in first-time pregnancy it can take up to 20
hours. The second stage extends from full dilation to birth and takes an average of 20 to 50
minutes, although 2 hours is still considered normal. The third stage extends from birth to
expulsion of the placenta and usually takes a few minutes. The fourth stage begins after
expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours).

Question 16

With regard to the turns and other adjustments of the fetus during the birth process, known as
the mechanism of labor, nurses should be aware that:
a. the seven critical movements must progress in a more or less orderly sequence.
b. asynclitism sometimes is achieved by means of the Leopold maneuver.
c. the effects of the forces determining descent are modified by the shape of the
woman’s pelvis and the size of the fetal head.
d. at birth the baby is said to achieve “restitution” (i.e., a return to the C-shape of the
womb).

Answer 16

ANS: C
The size of the maternal pelvis and the ability of the fetal head to mold also affect the process.
The seven identifiable movements of the mechanism of labor occur in combinations
simultaneously, not in precise sequences. Asynclitism is the deflection of the baby’s head; the
Leopold maneuver is a means of judging descent by palpating the mother’s abdomen.
Restitution is the rotation of the baby’s head after the infant is born.

Question 17

In order to evaluate the condition of the patient accurately during labor, the nurse should be
aware that:
a. the woman’s blood pressure will increase during contractions and fall back to prelabor normal between contractions.
b. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia.
c. having the woman point her toes will reduce leg cramps.
d. the endogenous endorphins released during labor will raise the woman’s pain
threshold and produce sedation.

Answer 17

ANS: D
The endogenous endorphins released during labor will raise the woman’s pain threshold and
produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the
pressure of the presenting part, decreases the mother’s perception of pain. Blood pressure
increases during contractions but remains somewhat elevated between them. Use of the
Valsalva maneuver is discouraged during second-stage labor because of a number of
unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can
the process of labor itself

Question 18

The maternity nurse understands that as the uterus contracts during labor, maternal-fetal
exchange of oxygen and waste products:
a. continues except when placental functions are reduced.
b. increases as blood pressure decreases.
c. diminishes as the spiral arteries are compressed.
d. is not significantly affected.

Answer 18

ANS: C
Uterine contractions during labor tend to decrease circulation through the spiral electrodes and
subsequent perfusion through the intervillous space. The maternal blood supply to the
placenta gradually stops with contractions. The exchange of oxygen and waste products
decreases. The exchange of oxygen and waste products is affected by contractions

Question 19

Which statement is the best rationale for assessing maternal vital signs between contractions?

a. During a contraction, assessing fetal heart rates is the priority.
b. Maternal circulating blood volume increases temporarily during contractions.
c. Maternal blood flow to the heart is reduced during contractions.
d. Vital signs taken during contractions are not accurate.

Answer 19

ANS: B
During uterine contractions, blood flow to the placenta temporarily stops, causing a relative
increase in the mother’s blood volume, which in turn temporarily increases blood pressure and
slows pulse. It is important to monitor fetal response to contractions; however, this question is
concerned with the maternal vital signs. Maternal blood flow is increased during a
contraction. Vital signs are altered by contractions but are considered accurate for that period
of time

Question 20

In order to care for obstetric patients adequately, the nurse understands that labor contractions
facilitate cervical dilation by:
a. contracting the lower uterine segment.
b. enlarging the internal size of the uterus.
c. promoting blood flow to the cervix.
d. pulling the cervix over the fetus and amniotic sac.

Answer 20

ANS: D
Effective uterine contractions pull the cervix upward at the same time that the fetus and
amniotic sac are pushed downward. The contractions are stronger at the fundus. The internal
size becomes smaller with the contractions; this helps to push the fetus down. Blood flow
decreases to the uterus during a contraction.

Question 21

To teach patients about the process of labor adequately, the nurse knows that which event is
the best indicator of true labor?
a. Bloody show
b. Cervical dilation and effacement
c. Fetal descent into the pelvic inlet
d. Uterine contractions every 7 minutes

Answer 21

ANS: B
The conclusive distinction between true and false labor is that contractions of true labor cause
progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can
occur before true labor. False labor may have contractions that occur this frequently; however,
this is usually inconsistent.

Question 22

Which occurrence is associated with cervical dilation and effacement?

a. Bloody show
b. False labor
c. Lightening
d. Bladder distention

Answer 22

ANS: A
As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the
cervix during pregnancy occurs. This causes rupture of small cervical capillaries. Cervical
dilation and effacement do not occur with false labor. Lightening is the descent of the fetus
toward the pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied
frequently. It may slow down the descent of the fetus during labor

Question 23

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The
fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in
duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from
admission). Membranes are intact. The nurse should expect the woman to be:
a. admitted and prepared for a cesarean birth.
b. admitted for extended observation.
c. discharged home with a sedative.
d. discharged home to await the onset of true labor.

Answer 23

ANS: D
This situation describes a woman with normal assessments who is probably in false labor and
will probably not deliver rapidly once true labor begins. These are all indications of false
labor without fetal distress. There is no indication that further assessment or cesarean birth is
indicated. The patient will likely be discharged; however, there is no indication that a sedative
is needed.

Question 24

Which nursing assessment indicates that a woman who is in second-stage labor is almost
ready to give birth?
a. The fetal head is felt at 0 station during vaginal examination.
b. Bloody mucus discharge increases.
c. The vulva bulges and encircles the fetal head.
d. The membranes rupture during a contraction.

Answer 24

ANS: C
During the active pushing (descent) phase, the woman has strong urges to bear down as the
presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.
The vulva stretches and begins to bulge encircling the fetal head. Birth of the head occurs
when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the
labor process and is not an indication of an imminent birth. Rupture of membranes can occur
at any time during the labor process and does not indicate an imminent birth.

Question 25

Signs that precede labor include: (Select all that apply.) a. lightening. b. exhaustion. c. bloody show. d. rupture of membranes. e. decreased fetal movement.

Answer 25

ANS: A, C, D Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor.

Question 26

Which factors influence cervical dilation? (Select all that apply.) a. Strong uterine contractions. b. The force of the presenting fetal part against the cervix. c. The size of the female pelvis. d. The pressure applied by the amniotic sac. e. Scarring of the cervix

Answer 26

ANS: A, B, D, E Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size does not affect cervical dilation.

Question 27

An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, “My contractions are so strong that I don’t know what to do with myself.” The nurse should: a. assess for fetal well-being. b. encourage the woman to lie on her side. c. disturb the woman as little as possible. d. recognize that pain is personalized for each individual.

Answer 27

ANS: D Each woman’s pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This patient clearly needs support

Question 28

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? a. Massaging the woman’s back b. Changing the woman’s position c. Giving the prescribed medication d. Encouraging the woman to rest between contractions

Answer 28

ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord and thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman’s position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.

Question 29

A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

Answer 29

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial because of its effects on the neonate

Question 30

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. limit parenteral fluids. b. monitor the fetus for possible tachycardia. c. monitor the maternal blood pressure for possible hypotension. d. monitor the maternal pulse for possible bradycardia.

Answer 30

ANS: C The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension

Question 31

The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. the mother gives birth without any analgesic or anesthetic. b. the mother and family’s priorities and preferences are incorporated into the plan. c. the primary health care provider decides the best pain relief for the mother and family. d. the nurse informs the family of all alternative methods of pain relief available in the hospital setting.

Answer 31

ANS: B The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.

Question 32

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling light-headed and dizzy and states that her fingers are tingling. The nurse should: a. notify the woman’s physician. b. tell the woman to slow the pace of her breathing. c. administer oxygen via a mask or nasal cannula. d. help her breathe into a paper bag.

Answer 32

ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion.

Question 33

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 33

ANS: A Counterpressure is a 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. The pain-management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.

Question 34

If an opioid antagonist is administered to a laboring woman, she should be told that: a. her pain will decrease. b. her pain will return. c. she will feel less anxious. d. she will no longer feel the urge to push.

Answer 34

ANS: B The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect.

Question 35

The role of the nurse with regard to informed consent is to: a. inform the patient about the procedure and have her sign the consent form. b. act as a patient advocate and help clarify the procedure and the options. c. call the physician to see the patient. d. witness the signing of the consent form

Answer 35

ANS: B Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman’s advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the patient about potential risk factors. The physician must be present to explain the procedure to the patient. However, the nurse’s responsibilities go further than simply asking the physician to see the patient. The nurse may witness the signing of the consent form. However, depending on the state’s guidelines, the woman’s husband or another hospital health care employee may sign as witness.

Question 36

A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics are often used with sedatives because: a. “The two together work the best for you and your baby.” b. “Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea.” c. “They work better together so you can sleep until you have the baby.” d. “This is what the doctor has ordered for you.

Answer 36

ANS: B Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications will not occur. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. “This is what the doctor has ordered for you” may be true, but it is not an acceptable comment for the nurse to make

Question 37

To help patients manage discomfort and pain during labor, nurses should be aware that: a. the predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. referred pain is the extreme discomfort between contractions. c. the somatic pain of the second stage of labor is more generalized and related to fatigue. d. pain during the third stage is a somewhat milder version of the second stage.

Answer 37

ANS: A This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.

Question 38

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions are experiencing more pain. d. Levels of pain-mitigating -endorphins are higher during a spontaneous, natural childbirth.

Answer 38

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.

Question 39

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help patients. Nurses should know that _____ women may be stoic until late in labor, when they may become vocal and request pain relief. a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

Answer 39

ANS: C Hispanic women may be stoic early and more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start. They may prefer pain medications. African-American women may express pain openly; use of medications for pain is more likely to vary with the individual.

Question 40

With regard to a pregnant woman’s anxiety and pain experience, nurses should be aware that: a. even mild anxiety must be treated. b. severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. c. anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

Answer 40

ANS: B Anxiety and pain reinforce each other in a negative cycle. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy

Question 41

Nurses should be aware of the differences experience can make in labor pain 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 41

ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is higher for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Question 42

In the current practice of childbirth preparation, emphasis is placed on: a. the Dick-Read (natural) childbirth method. b. the Lamaze (psychoprophylactic) method. c. the Bradley (husband-coached) method. d. having expectant parents attend childbirth preparation in any or no specific method.

Answer 42

ANS: D Encouraging expectant parents to attend childbirth preparation class is most important because preparation increases a woman’s confidence and thus her ability to cope with labor and birth. Although still popular, the “method” format of classes is being replaced with other offerings such as Hypnobirthing and Birthing from Within.

Question 43

With regard to breathing techniques during labor, maternity nurses should understand that: a. breathing techniques 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 near the end of the second stage of labor. d. the patterned-paced breathing technique can help prevent hyperventilation.

Answer 43

ANS: A First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

Question 44

Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a. music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. effleurage is permissible, but counterpressure is almost always counterproductive. d. electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

Answer 44

ANS: D Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks may be more effective than a long soak. Counterpressure can help the woman cope with lower back pain.

Question 45

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 (IM) administration is preferred over intravenous (IV) administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

Answer 45

ANS: B Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.

Question 46

With regard to nerve block analgesia and anesthesia, nurses should be aware that: a. most local agents are related chemically to cocaine and end in the suffix -caine. b. local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. a pudendal nerve block is designed to relieve the pain from uterine contractions. d. a pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex

Answer 46

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex.

Question 47

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 47

ANS: B Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman’s ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

Question 48

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is: a. not used much anymore. b. likely to be used in the second stage of labor but not in the first stage. c. an application of nitrous oxide. d. a prelude to cesarean birth.

Answer 48

ANS: C This is an application of nitrous oxide, which could be used in either the first or second stage of labor (or both) as part of the preparation for a vaginal birth. Nitrous oxide is self-administered and found to be very helpful.

Question 49

After change-of-shift report the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. visceral. b. referred. c. somatic. d. afterpain

Answer 49

ANS: B As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early after birth period is uterine. This pain is very similar to that experienced in the first stage of labor.

Question 50

It is important for the nurse to develop a realistic birth plan with the pregnant woman in her care. The nurse can explain that a major advantage of nonpharmacologic pain management is: a. greater and more complete pain relief is possible. b. no side effects or risks to the fetus are involved. c. the woman remains fully alert at all times. d. a more rapid labor is likely.

Answer 50

ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The woman’s alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace

Question 51

The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic analgesia in the newborn is: a. respiratory depression. b. bradycardia. c. acrocyanosis. d. tachypnea.

Answer 51

ANS:A An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase.

Question 52

``` The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called: a. an epidural. b. a pudendal. c. a local. d. a spinal block ```

Answer 52

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

Question 53

``` Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation? a. Epidural anesthesia b. Narcotics c. Spinal block d. Breathing and relaxation techniques ```

Answer 53

ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. It is unlikely that enough time remains to administer epidural or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn.

Question 54

``` The laboring woman who imagines her body opening to let the baby out is using a mental technique called: a. dissociation. b. effleurage. c. imagery. d. distraction. ```

Answer 54

ANS:C Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman engage in another activity.

Question 55

The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is: a. respiratory depression. b. uterine relaxation. c. inadequate muscle relaxation. d. aspiration of stomach contents.

Answer 55

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

Question 56

``` To assist the woman after delivery of the infant, the nurse knows that the blood patch is used after spinal anesthesia to relieve: a. hypotension. b. headache. c. neonatal respiratory depression. d. loss of movement. ```

Answer 56

ANS: B The subarachnoid block may cause a postspinal headache resulting from loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.

Question 57

``` 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? (Select 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 57

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman’s legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the patient in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure

Question 58

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would include: (Select all that apply.) a. yawning, runny nose. b. increase in appetite. c. chills and hot flashes. d. constipation. e. irritability, restlessness.

Answer 58

ANS: A, C, E The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It is important for the nurse to assess both mother and baby and to plan care accordingly.

Question 59

``` While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman’s experience of pain. These include: (Select all that apply.) a. culture. b. anxiety and fear. c. previous experiences with pain. d. intervention of caregivers. e. support systems. ```

Answer 59

ANS;A,B,C,E Culture: A woman’s sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a woman’s ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: Fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: An anxious partner is less able to provide help and support to a woman during labor. A woman’s family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, intravenous lines).

Question 60

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 60

ANS: 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 61

The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman’s understanding of the instructions when she states, “True labor contractions will: a. subside when I walk around.” b. cause discomfort over the top of my uterus.” c. continue and get stronger even if I relax and take a shower.” d. remain irregular but become stronger.”

Answer 61

ANS: C True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.

Question 62

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 62

ANS: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 the assessment and gather data. The amniotic membranes may or may not spontaneously rupture during labor. The patient may be instructed to stay home until the uterine contractions become strong and regular. 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 patient or her primary health care provider. Before instructing the woman to come to the hospital, the nurse should initiate the assessment during the telephone interview.

Question 63

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 63

ANS: A When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause 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 64

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 64

ANS: C The nurse or primary 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 that 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 65

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: a. dilation of the cervix. b. descent of the fetus. c. rupture of the amniotic membranes. d. increase in bloody show.

Answer 65

ANS: 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 66

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 66

ANS: 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 to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.

Question 67

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse’s initial response would be 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 67

ANS: 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 care provider after ROM occurs and fetal well-being and the 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 68

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

Answer 68

ANS: 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.” 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 69

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 69

ANS: 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 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 70

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: a. encouraging the woman to try various upright positions, including squatting and standing. b. telling the woman to start pushing as soon as her cervix is fully dilated. c. continuing an epidural anesthetic so pain is reduced and the woman can relax. d. coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.

Answer 70

ANS:A Upright positions and squatting both may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to “labor down” (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if the woman is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia.

Question 71

Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: a. first stage, latent phase. b. first stage, active phase. c. first stage, transition phase. d. second stage, latent phase

Answer 71

ANS: B The first stage, active phase of 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 would be 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 72

The most critical nursing action in caring for the newborn immediately after birth is: a. keeping the newborn’s airway clear. b. fostering parent-newborn attachment. c. drying the newborn and wrapping the infant in a blanket. d. administering eyedrops and vitamin K.

Answer 72

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

Question 73

When assessing a multiparous woman who has just given birth to an 8-lb boy, the nurse notes that the woman’s fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that: a. the placenta has separated. b. a cervical tear occurred during the birth. c. the woman is beginning to hemorrhage. d. clots have formed in the upper uterine segment.

Answer 73

ANS: A Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.

Question 74

``` 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 74

ANS: B Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain or prevent infection. They cause the uterus to contract, which reduces blood loss. Oxytocics do not facilitate rest and relaxation.

Question 75

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to: a. facilitate maternal-newborn interaction. b. stimulate the uterus to contract. c. prevent neonatal hypoglycemia. d. initiate the lactation cycle.

Answer 75

ANS:B Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin, which prevents hemorrhage. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth.

Question 76

A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that “true” labor contractions: a. increase with activity such as ambulation. b. decrease with activity. c. are always accompanied by the rupture of the bag of waters. d. alternate between a regular and an irregular pattern.

Answer 76

ANS: A True labor contractions become more intense with walking. False labor contractions often stop with walking or position changes. Rupture of membranes may occur before or during labor. True labor contractions are regular.

Question 77

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse’s best response is: a. “Don’t worry about it. You’ll do fine.” b. “It’s normal to be anxious about labor. Let’s discuss what makes you afraid.” c. “Labor is scary to think about, but the actual experience isn’t.” d. “You can have an epidural. You won’t feel anything.”

Answer 77

ANS: B “It’s normal to be anxious about labor. Let’s discuss what makes you afraid” allows the woman to share her concerns with the nurse and is a therapeutic communication tool. “Don’t worry about it. You’ll do fine” negates the woman’s fears and is not therapeutic. “Labor is scary to think about, but the actual experience isn’t” negates the woman’s fears and offers a false sense of security. It is not true that every woman may have an epidural. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural

Question 78

For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of: a. the onset of progressive, regular contractions. b. the bloody, or pink, show. c. the spontaneous rupture of membranes. d. formulation of the woman’s plan of care for labor.

Answer 78

ANS: D Labor care begins when progressive, regular contractions begin; the blood-tinged mucoid vaginal discharge appears; or fluid is discharged from the vagina. The woman and nurse can formulate their plan of care before labor or during treatment.

Question 79

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 79

ANS: 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 80

It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care? a. The patient 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. The woman can have only her male partner or predesignated “doula” with her at assessment. c. The patient’s weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth. d. The nurse may exchange information about the patient with family members.

Answer 80

ANS: C 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 can have anyone she wishes present for her support. The risk for CPD is especially great for petite women or those who have gained 16 kg or more. All patients should have their weight and BMI calculated on admission. This is part of standard nursing care on a maternity unit and not a regulatory concern. According to the Health Insurance Portability and Accountability Act (HIPAA), the patient must give consent for others to receive any information related to her condition.

Question 81

Leopold maneuvers would be an inappropriate method of assessment to determine: a. gender of the fetus. b. number of fetuses. c. fetal lie and attitude. d. degree of the presenting part’s descent into the pelvis.

Answer 81

ANS: A Leopold maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus is not a goal of the examination at this time.

Question 82

In documenting labor experiences, nurses should know that a uterine contraction is described according to all 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 82

ANS: D | Uterine contractions are described in terms of frequency, intensity, duration, and resting tone

Question 83

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) 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 83

ANS: C Nurses should be prepared for the shift. The PMI of the FHT 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 84

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. intravenous (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 84

ANS: 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. A multiparous woman may feel the urge to defecate and it may mean birth will follow quickly, but not for a first timer.

Question 85

If a woman complains of back labor pain, the nurse could best suggest that she: a. lie on her back for a while with her knees bent. b. do less walking around. c. take some deep, cleansing breaths. d. lean over a birth ball with her knees on the floor.

Answer 85

ANS: D The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged

Question 86

Which description of the phases of the second stage of labor is accurate? a. Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied d. Transitional phase: Woman “laboring down,” fetal station 0, duration 15 minutes

Answer 86

ANS: C The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or “laboring down,” period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.

Question 87

Nurses alert to signs of the onset of the second stage of labor can be certain that this 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 bears down

Answer 87

ANS: 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. Vomiting, an increase in bloody show, and involuntary bearing down are only suggestions of second-stage labor.

Question 88

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 88

ANS: 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 89

Which collection of risk factors most likely would 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 89

ANS: D Reddish-haired women have tissue that is less distensible than that of darker-skinned women and therefore 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.

Question 90

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 90

ANS: B Active management facilitates placental separation and expulsion, thus 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 after birth hemorrhage.

Question 91

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman 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 patient 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 the patient view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care? a. Telling the patient to relax and that it won’t hurt much. b. Limiting the number of procedures that invade her body. c. Reassuring the patient that as the nurse you know what is best. d. Allowing unlimited care providers to be with the patient

Answer 91

ANS: B The number of invasive procedures such as vaginal examinations, internal monitoring, and intravenous therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the patient’s recalling the phrases of her abuser (e.g., “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 patient’s pace and wait for permission to proceed. Protecting the patient’s environment by providing privacy and limiting the number of staff who observe the patient will help to make her feel safe.

Question 92

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 culturally diverse practices and learn to incorporate these into a mutually agreed on 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 would anticipate that a woman from which country would have the father of the baby in attendance? a. Mexico b. China c. Iran d. India

Answer 92

ANS: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. Fathers are usually not present in China. The Iranian father will not be present. Female support persons and female care providers are preferred. For many, a male caregiver is unacceptable. The father is usually not present in India, but female relatives are usually present. Natural childbirth methods are preferred.

Question 93

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage

Answer 93

ANS: B The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta. This patient is in the active phase of labor.

Question 94

The primary difference between the labor of a nullipara and that of a multipara is the: a. amount of cervical dilation. b. total duration of labor. c. level of pain experienced. d. sequence of labor mechanisms.

Answer 94

ANS: B Multiparas usually labor more quickly than nulliparas, thus making the total duration of their labor shorter. Cervical dilation is the same for all labors. The level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms remains the same with all labors.

Question 95

A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are: a. contraction pattern, amount of discomfort, and pregnancy history. b. fetal heart rate, maternal vital signs, and the woman’s nearness to birth. c. identification of ruptured membranes, the woman’s gravida and para, and her support person. d. last food intake, when labor began, and cultural practices the couple desires.

Answer 95

ANS:B All options describe relevant intrapartum nursing assessments; however, this focused assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. This includes: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices.

Question 96

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. admitted and prepared for a cesarean birth. b. admitted for extended observation. c. discharged home with a sedative. d. discharged home to await the onset of true labor.

Answer 96

ANS: D This situation describes a woman with normal assessments who is probably in false labor and will likely not deliver rapidly once true labor begins. There is no indication that further assessments or observations are indicated; therefore, the patient will be discharged along with instructions to return when contractions increase in intensity and frequency. Neither a cesarean birth nor a sedative is required at this time.

Question 97

A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to: a. ask her to turn to one side. b. elevate her feet and legs. c. take her blood pressure. d. determine whether fetal tachycardia is present.

Answer 97

ANS: A The woman’s supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental blood flow. Elevating her legs will not relieve the pressure from the inferior vena cava. If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side. Blood pressure readings may be obtained when the patient is in the appropriate and safest position.

Question 98

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

Answer 98

ANS: C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.

Question 99

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant’s trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant? a. 7 b. 8 c. 9 d. 10

Answer 99

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant’s blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant’s hands and feet were blue, this category is given a grade of 1.

Question 100

The nurse thoroughly dries the infant immediately after birth primarily to: a. stimulate crying and lung expansion. b. remove maternal blood from the skin surface. c. reduce heat loss from evaporation. d. increase blood supply to the hands and feet.

Answer 100

ANS: C Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Rubbing the infant does stimulate crying; however, it is not the main reason for drying the infant. This process does not remove all the maternal blood.