Question 1

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor?

Accepted Answer

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." 
A)  "I passed some thick, pink mucus when I urinated this morning." 
B)  "My bag of waters just broke." 
C)  "The contractions in my uterus are getting stronger and closer together." 
D)  "My baby dropped, and I have to urinate more frequently now." C

Question 2

Which component of the physical examination are Leopold's maneuvers unable to determine?

Accepted Answer

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 
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 A

Question 3

Which statement concerning the third stage of labor is correct?

Accepted Answer

A)  The placenta eventually detaches itself from a flaccid uterus. 
B)  An expectant or active approach to managing this stage of labor reduces the risk of complications. 
C)  It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface. 
D)  The major risk for women during the third stage is a rapid heart rate. 
A)  The placenta eventually detaches itself from a flaccid uterus. 
B)  An expectant or active approach to managing this stage of labor reduces the risk of complications. 
C)  It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface. 
D)  The major risk for women during the third stage is a rapid heart rate. B

Question 4

Where is the point of maximal intensity (PMI)of the FHR located?

Accepted Answer

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 internally rotates 
D)  In a breech position, heard below the mother's umbilicus 
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 internally rotates 
D)  In a breech position, heard below the mother's umbilicus

Question 5

In recovery,if a woman is asked to either raise her legs (knees extended)off the bed or flex her knees,and then place her feet flat on the bed and raise her buttocks well off the bed,the purpose of this exercise is to assess what?

Accepted Answer

A)  Recovery from epidural or spinal anesthesia 
B)  Hidden bleeding underneath her 
C)  Flexibility 
D)  Whether the woman is a candidate to go home after 6 hours 
A)  Recovery from epidural or spinal anesthesia 
B)  Hidden bleeding underneath her 
C)  Flexibility 
D)  Whether the woman is a candidate to go home after 6 hours

Question 6

Which characteristic of a uterine contraction is not routinely documented?

Accepted Answer

A)  Frequency: how often contractions occur 
B)  Intensity: strength of the contraction at its peak 
C)  Resting tone: tension in the uterine muscle 
D)  Appearance: shape and height 
A)  Frequency: how often contractions occur 
B)  Intensity: strength of the contraction at its peak 
C)  Resting tone: tension in the uterine muscle 
D)  Appearance: shape and height

Question 7

A woman who is gravida 3 para 2 arrives on the intrapartum unit.What is the most important nursing assessment at this time?

Accepted Answer

A)  Contraction pattern, amount of discomfort, and pregnancy history 
B)  FHR, maternal vital signs, and the woman's nearness to birth 
C)  Identification of ruptured membranes, woman's gravida and para, and her support person 
D)  Last food intake, when labor began, and cultural practices the couple desires 
A)  Contraction pattern, amount of discomfort, and pregnancy history 
B)  FHR, maternal vital signs, and the woman's nearness to birth 
C)  Identification of ruptured membranes, woman's gravida and para, and her support person 
D)  Last food intake, when labor began, and cultural practices the couple desires

Question 8

A multiparous woman has been in labor for 8 hours.Her membranes have just ruptured.What is the nurse's highest priority in this situation?

Accepted Answer

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 (FHR) and pattern. 
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 (FHR) and pattern.

Question 9

When assessing a woman in the first stage of labor,which clinical finding will alert the nurse that uterine contractions are effective?

Accepted Answer

A)  Dilation of the cervix 
B)  Descent of the fetus to -2 station 
C)  Rupture of the amniotic membranes 
D)  Increase in bloody show 
A)  Dilation of the cervix 
B)  Descent of the fetus to -2 station 
C)  Rupture of the amniotic membranes 
D)  Increase in bloody show

Question 10

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

-Step 4

Accepted Answer

A) After obtaining permission, gently insert the index and middle fingers into the vagina. 
B) Explain the findings to the client. 
C) Position the woman to prevent supine hypotension. 
D) Use sterile gloves and soluble gel for lubrication. 
E) Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid. 
A) After obtaining permission, gently insert the index and middle fingers into the vagina. 
B) Explain the findings to the client. 
C) Position the woman to prevent supine hypotension. 
D) Use sterile gloves and soluble gel for lubrication. 
E) Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 11

When a nulliparous woman telephones the hospital to report that she is in labor,what guidance should the nurse provide or information should the nurse obtain?

Accepted Answer

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. 
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.

Question 12

The vaginal examination is an essential component of labor assessment. It reveals whether the client is in true labor and enables the examiner to determine whether membranes have ruptured. The vaginal examination is often stressful and uncomfortable for the client and should be performed only when indicated. Match the correct step number, from 1 to 7, with each component of a vaginal examination of the laboring woman.

-Step 7

Accepted Answer

A) After obtaining permission, gently insert the index and middle fingers into the vagina. 
B) Explain the findings to the client. 
C) Position the woman to prevent supine hypotension. 
D) Use sterile gloves and soluble gel for lubrication. 
E) Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid. 
A) After obtaining permission, gently insert the index and middle fingers into the vagina. 
B) Explain the findings to the client. 
C) Position the woman to prevent supine hypotension. 
D) Use sterile gloves and soluble gel for lubrication. 
E) Document findings and report to the health care provider.
F)Cleanse the perineum and vulva, if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 13

Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position?

Accepted Answer

A)  Occiput of the fetus is in a posterior position. 
B)  Fetus is at or above the ischial spines. 
C)  Fetus is in a vertex presentation. 
D)  Membranes have ruptured. 
A)  Occiput of the fetus is in a posterior position. 
B)  Fetus is at or above the ischial spines. 
C)  Fetus is in a vertex presentation. 
D)  Membranes have ruptured.

Question 14

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.Which instruction best describes these measures?

Accepted Answer

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 
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

Question 15

The nurse performs a vaginal examination to assess a client's labor progress.Which action should the nurse take next?

Accepted Answer

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. 
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.

Question 16

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit.The FHR 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.What disposition would the nurse anticipate?

Accepted Answer

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 
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

Question 17

The first 1 to 2 hours after birth is sometimes referred to as what?

Accepted Answer

A)  Bonding period 
B)  Third stage of labor 
C)  Fourth stage of labor 
D)  Early postpartum period 
A)  Bonding period 
B)  Third stage of labor 
C)  Fourth stage of labor 
D)  Early postpartum period

Question 18

What is the primary rationale for the thorough drying of the infant immediately after birth?

Accepted Answer

A)  Stimulates crying and lung expansion 
B)  Removes maternal blood from the skin surface 
C)  Reduces heat loss from evaporation 
D)  Increases blood supply to the hands and feet 
A)  Stimulates crying and lung expansion 
B)  Removes maternal blood from the skin surface 
C)  Reduces heat loss from evaporation 
D)  Increases blood supply to the hands and feet

Question 19

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed.Which situations are examples of such an emergency?
(Select all that apply).

Accepted Answer

A)  Nonreassuring or abnormal FHR pattern 
B)  Inadequate uterine relaxation 
C)  Vaginal bleeding 
D)  Prolonged second stage 
E)  Prolapse of the cord 
A)  Nonreassuring or abnormal FHR pattern 
B)  Inadequate uterine relaxation 
C)  Vaginal bleeding 
D)  Prolonged second stage 
E)  Prolapse of the cord

Question 20

The nurse should be aware of which information related to a woman's intake and output during labor?

Accepted Answer

A)  Traditionally, 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 are usually 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 quickly follow. 
A)  Traditionally, 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 are usually 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 quickly follow.

Exam 19: Nursing Care of the Family During Labor and Birth

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor?

Which component of the physical examination are Leopold's maneuvers unable to determine?

Which statement concerning the third stage of labor is correct?

Where is the point of maximal intensity (PMI)of the FHR located?

In recovery,if a woman is asked to either raise her legs (knees extended)off the bed or flex her knees,and then place her feet flat on the bed and raise her buttocks well off the bed,the purpose of this exercise is to assess what?

Which characteristic of a uterine contraction is not routinely documented?

A woman who is gravida 3 para 2 arrives on the intrapartum unit.What is the most important nursing assessment at this time?

A multiparous woman has been in labor for 8 hours.Her membranes have just ruptured.What is the nurse's highest priority in this situation?

When assessing a woman in the first stage of labor,which clinical finding will alert the nurse that uterine contractions are effective?

When a nulliparous woman telephones the hospital to report that she is in labor,what guidance should the nurse provide or information should the nurse obtain?

Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position?

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.Which instruction best describes these measures?

The nurse performs a vaginal examination to assess a client's labor progress.Which action should the nurse take next?

The first 1 to 2 hours after birth is sometimes referred to as what?

What is the primary rationale for the thorough drying of the infant immediately after birth?

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed.Which situations are examples of such an emergency? (Select all that apply).

The nurse should be aware of which information related to a woman's intake and output during labor?

21st Century Maternity and Women’s Health Nursing

Community Care: The Family and Culture

Nursing and Genomics

Assessment and Health Promotion

Violence Against Women

Reproductive System Concerns

Sexually Transmitted and Other Infections

Contraception and Abortion

Infertility

Problems of the Breast

Structural Disorders and Neoplasms of the Reproductive System

Conception and Fetal Development

Anatomy and Physiology of Pregnancy

Nursing Care of the Family During Pregnancy

Maternal and Fetal Nutrition

Labor and Birth Processes

Maximizing Comfort for the Laboring Woman

Fetal Assessment During Labor

Postpartum Physiologic Changes

Nursing Care of the Family During the Postpartum Period

Transition to Parenthood

Physiologic and Behavioral Adaptations of the Newborn

Nursing Care of the Newborn and Family

Newborn Nutrition and Feeding

Assessment of High Risk Pregnancy

Hypertensive Disorders

Hemorrhagic Disorders

Endocrine and Metabolic Disorders

Medical-Surgical Disorders

Mental Health Disorders and Substance Abuse

Labor and Birth Complications

Postpartum Complications

Nursing Care of the High Risk Newborn

Acquired Problems of the Newborn

Hemolytic Disorders and Congenital Anomalies

Perinatal Loss, Bereavement, and Grief

Filters