Question 1

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

Accepted Answer

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 eye drops and vitamin K. 
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 eye drops and vitamin K. A

Question 2

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions?

Accepted Answer

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. 
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. C

Question 3

Concerning the third stage of labor,nurses should be aware that:

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

Question 4

A laboring woman is lying in the supine position.The most appropriate nursing action at this time is to:

Accepted Answer

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. 
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.

Question 5

Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)?

Accepted Answer

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 
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

Question 6

In documenting labor experiences,nurses should know that a uterine contraction is described according to all these characteristics except:

Accepted Answer

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). 
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).

Question 7

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?

Accepted Answer

A) 7 
B) 8 
C) 9 
D) 10 
A) 7 
B) 8 
C) 9 
D) 10

Question 8

A woman who is gravida 3 para 2 enters the intrapartum unit.The most important nursing assessments are:

Accepted Answer

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. 
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.

Question 9

What is an essential part of nursing care for the laboring woman?

Accepted Answer

A) Helping the woman manage the pain 
B) Eliminating the pain associated with labor 
C) Sharing personal experiences regarding labor and delivery to decrease her anxiety 
D) Feeling comfortable with the predictable nature of intrapartum care 
A) Helping the woman manage the pain 
B) Eliminating the pain associated with labor 
C) Sharing personal experiences regarding labor and delivery to decrease her anxiety 
D) Feeling comfortable with the predictable nature of intrapartum care

Question 10

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 client to associate the sensations of labor with the process of childbirth and not the past abuse.The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner.Which intervention would be key for the nurse to use while providing care?

Accepted Answer

A) Telling the client to relax and that it won't hurt much 
B) Limiting the number of procedures that invade her body 
C) Reassuring the client that as the nurse you know what is best 
D) Allowing unlimited care providers to be with the client 
A) Telling the client to relax and that it won't hurt much 
B) Limiting the number of procedures that invade her body 
C) Reassuring the client that as the nurse you know what is best 
D) Allowing unlimited care providers to be with the client

Question 11

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

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 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 and pattern.

Question 12

The vaginal examination is an essential component of labor assessment. It reveals whether the patient is in true labor and enables the examiner to determine whether membranes have ruptured. This examination is often stressful and uncomfortable for the patient and should be performed only when indicated. Please 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 findings to the patient. 
C) Position the woman to prevent supine hypotension. 
D) Use sterile gloves and soluble gel for lubrication. 
E) Document findings and report to the 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 findings to the patient. 
C) Position the woman to prevent supine hypotension. 
D) Use sterile gloves and soluble gel for lubrication. 
E) Document findings and report to the provider.
F)Cleanse the perineum and vulva if necessary.
G)Determine dilation, presenting part, status of membranes, and characteristics of amniotic fluid.

Question 13

The labor process is an exciting and anxious time for the patient and her partner and family. In a relatively short period of time, they experience one of the most profound changes in their lives. Nursing care management focuses on assessment and support throughout labor and birth, with the goal of ensuring the best possible outcome for mother and newborn. Please match each nursing diagnosis with the appropriate intervention needed to achieve the expected outcome.

-Group care activities as much as possible.

Accepted Answer

A) Anxiety related to labor and the birthing process 
B) Acute pain related to contractions 
C) Risk for impaired urinary elimination 
D) Risk for impaired individual coping 
E) Fatigue related to energy expenditure during labor and birth 
A) Anxiety related to labor and the birthing process 
B) Acute pain related to contractions 
C) Risk for impaired urinary elimination 
D) Risk for impaired individual coping 
E) Fatigue related to energy expenditure during labor and birth

Question 14

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

-Step 2

Accepted Answer

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

Question 15

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:

Accepted Answer

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. 
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.

Question 16

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:

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 17

Nurses can help their clients by keeping them informed about the distinctive stages of labor.What description of the phases of the first stage of labor is accurate?

Accepted Answer

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 
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

Question 18

The nurse who performs vaginal examinations to assess a woman's progress in labor should:

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 19

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:

Accepted Answer

A) First stage, latent phase. 
B) First stage, active phase. 
C) First stage, transition phase. 
D) Second stage, latent phase. 
A) First stage, latent phase. 
B) First stage, active phase. 
C) First stage, transition phase. 
D) Second stage, latent phase.

Question 20

The nurse recognizes that a woman is in true labor when she states:

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."

Exam 16: Nursing Care of the Family During Labor and Birth

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

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions?

Concerning the third stage of labor,nurses should be aware that:

A laboring woman is lying in the supine position.The most appropriate nursing action at this time is to:

Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)?

In documenting labor experiences,nurses should know that a uterine contraction is described according to all these characteristics except:

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 woman who is gravida 3 para 2 enters the intrapartum unit.The most important nursing assessments are:

What is an essential part of nursing care for the laboring woman?

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

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:

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:

Nurses can help their clients by keeping them informed about the distinctive stages of labor.What description of the phases of the first stage of labor is accurate?

The nurse who performs vaginal examinations to assess a woman's progress in labor should:

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:

The nurse recognizes that a woman is in true labor when she states:

21st Century Maternity Nursing

Community Care: the Family and Culture

Assessment and Health Promotion

Reproductive System Concerns

Infertility,contraception,and Abortion

Genetics, conception, and Fetal Development

Anatomy and Physiology of Pregnancy

Nursing Care of the Family During Pregnancy

Maternal and Fetal Nutrition

Assessment of High Risk Pregnancy

Pregnancy at Risk: Preexisting Conditions

Pregnancy at Risk: Gestational Conditions

Labor and Birth Processes

Pain Management

Fetal Assessment During Labor

Labor and Birth Complications

Maternal Physiologic Changes

Nursing Care of the Family During the Postpartum Period

Transition to Parenthood

Postpartum Complications

Physiologic and Behavioral Adaptations of the Newborn

Nursing Care of the Newborn and Family

Newborn Nutrition and Feeding

The High Risk Newborn

21st Century Pediatric Nursing

Family, social, cultural, and Religious Influences on Child Health Promotion

Developmental and Genetic Influences on Child Health Promotion

Communication, history, and Physical Assessment

Pain Assessment and Management in Children

The Infant and Family

The Toddler and Family

The Preschooler and Family

The School-Age Child and Family

The Adolescent and Family

Chronic Illness, disability, and End-Of-Life Care

Impact of Cognitive or Sensory Impairment on the Child and Family

Family-Centered Care of the Child During Illness and Hospitalization

Pediatric Variations of Nursing Interventions

Respiratory Dysfunction

Gastrointestinal Dysfunction

Cardiovascular Dysfunction

Hematologic and Immunologic Dysfunction

Genitourinary Dysfunction

Cerebral Dysfunction

Endocrine Dysfunction

Integumentary Dysfunction

Musculoskeletal or Articular Dysfunction

Neuromuscular or Muscular Dysfunction

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