Question 1

A nulliparous woman has just begun the latent phase of the second stage of her labor.The nurse should anticipate which behavior?

Accepted Answer

A)  A nulliparous woman will experience a strong urge to bear down. 
B)  Perineal bulging will show. 
C)  A nulliparous woman will remain quiet with her eyes closed between contractions. 
D)  The amount of bright red bloody show will increase.

Question 2

Through a vaginal examination,the nurse determines that a woman is 4 cm dilated.The external fetal monitor shows uterine contractions every3½ to 4 minutes.The nurse reports this as what stage of labor?

Accepted Answer

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

Question 3

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

Accepted Answer

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

Question 4

Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand?

Accepted Answer

A)  Client is considered to be in active labor when she arrives at the facility with contractions. 
B)  Client can have only her male partner or predesignated doula with her at assessment. 
C)  Children are not allowed on the labor unit. 
D)  Non-English speaking client must bring someone to translate.

Question 5

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

Accepted Answer

A)  Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips 
B)  Determining the frequency by timing from the end of one contraction to the end of the next contraction 
C)  Evaluating the intensity by pressing the fingertips into the uterine fundus 
D)  Assessing uterine contractions every 30 minutes throughout the first stage of labor

Question 6

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 2

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.

Question 7

Which description of the phases of the first stage of labor is most accurate?

Accepted Answer

A)  Latent: mild, regular contractions; no dilation; bloody show 
B)  Active: moderate, regular contractions; 4 to 7 cm dilation 
C)  Lull: no contractions; dilation stable 
D)  Transition: very strong but irregular contractions; 8 to 10 cm dilation

Question 8

What is the rationale for the administration of an oxytocic (e.g.,Pitocin,Methergine)after expulsion of the placenta?

Accepted Answer

A)  To relieve pain 
B)  To stimulate uterine contraction 
C)  To prevent infection 
D)  To facilitate rest and relaxation

Question 9

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and a tightening of the abdominal muscles.When is it appropriate to instruct the client to use this maneuver?

Accepted Answer

A)  During the second stage to enhance the movement of the fetus 
B)  During the third stage to help expel the placenta 
C)  During the fourth stage to expel blood clots 
D)  Not at all

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