Question 1

With regard to a woman's intake and output during labor,nurses should be aware that:

Accepted Answer

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. 
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.

Question 2

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:

Accepted Answer

A) Dilation of the cervix. 
B) Descent of the fetus. 
C) Rupture of the amniotic membranes. 
D) Increase in bloody show. 
A) Dilation of the cervix. 
B) Descent of the fetus. 
C) Rupture of the amniotic membranes. 
D) Increase in bloody show.

Question 3

After an emergency birth,the nurse encourages the woman to breastfeed her newborn.The primary purpose of this activity is to:

Accepted Answer

A) Facilitate maternal-newborn interaction. 
B) Stimulate the uterus to contract. 
C) Prevent neonatal hypoglycemia. 
D) Initiate the lactation cycle. 
A) Facilitate maternal-newborn interaction. 
B) Stimulate the uterus to contract. 
C) Prevent neonatal hypoglycemia. 
D) Initiate the lactation cycle.

Question 4

For the labor nurse,care of the expectant mother begins with any or all of these situations,with the exception of:

Accepted Answer

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. 
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.

Question 5

The nurse knows that the second stage of labor,the descent phase,has begun when:

Accepted Answer

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. 
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.

Question 6

The nurse thoroughly dries the infant immediately after birth primarily to:

Accepted Answer

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. 
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.

Question 7

Which description of the phases of the second stage of labor is accurate?

Accepted Answer

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 
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

Question 8

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:

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 9

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?

Accepted Answer

A) Latent phase 
B) Active phase 
C) Second stage 
D) Third stage 
A) Latent phase 
B) Active phase 
C) Second stage 
D) Third stage

Question 10

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.

-Continue to provide comfort measures and minimize distractions.

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 11

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.

-Instruct the patient and partner in the use of specific relaxation techniques.

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 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 4

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

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?

Accepted Answer

A) An admission to the hospital at the start of labor 
B) When accelerations of the fetal heart rate (FHR) are noted 
C) On maternal perception of perineal pressure or the urge to bear down 
D) When membranes rupture 
A) An admission to the hospital at the start of labor 
B) When accelerations of the fetal heart rate (FHR) are noted 
C) On maternal perception of perineal pressure or the urge to bear down 
D) When membranes rupture

Question 14

Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when:

Accepted Answer

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. 
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.

Question 15

A nulliparous woman who has just begun the second stage of her labor would most likely:

Accepted Answer

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. 
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.

Question 16

What is an expected characteristic of amniotic fluid?

Accepted Answer

A) Deep yellow color 
B) Pale, straw color with small white particles 
C) Acidic result on a Nitrazine test 
D) Absence of ferning 
A) Deep yellow color 
B) Pale, straw color with small white particles 
C) Acidic result on a Nitrazine test 
D) Absence of ferning

Question 17

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.

-Encourage frequent voiding and catheterize if necessary.

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 18

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?

Accepted Answer

A) Mexico 
B) China 
C) Iran 
D) India 
A) Mexico 
B) China 
C) Iran 
D) India

Question 19

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

Accepted Answer

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. 
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.

Question 20

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 3

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.

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

With regard to a woman's intake and output during labor,nurses should be aware that:

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:

After an emergency birth,the nurse encourages the woman to breastfeed her newborn.The primary purpose of this activity is to:

For the labor nurse,care of the expectant mother begins with any or all of these situations,with the exception of:

The nurse knows that the second stage of labor,the descent phase,has begun when:

The nurse thoroughly dries the infant immediately after birth primarily to:

Which description of the phases of the second stage of labor is accurate?

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination?

Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when:

A nulliparous woman who has just begun the second stage of her labor would most likely:

What is an expected characteristic of amniotic fluid?

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

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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