Question 1

Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

Accepted Answer

A)  Anterior fontanel 
B)  Coronal suture lines 
C)  Posterior fontanel 
D)  Biparietal diameter

Question 2

The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

Accepted Answer

A)  Soft boggy uterus 
B)  Maternal temperature of 37.2°C (99°F) 
C)  High uterine fundus displaced to the right 
D)  Intense vaginal pain unrelieved by analgesics 
E)  Half of a lochia pad saturated in the first hour after birth

Question 3

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?

Accepted Answer

A)  18-gauge 
B)  20-gauge 
C)  22-gauge 
D)  24-gauge

Question 4

Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?

Accepted Answer

A)  Recommend frequent position changes. 
B)  Palpate her filling bladder every 15 minutes. 
C)  Offer warm wet cloths to use on the patient's face and neck. 
D)  Keep the room lights lit so the patient and her coach can see everything.

Question 5

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

Accepted Answer

A)  Bloody 
B)  Clear with bits of vernix caseosa 
C)  Green and thick 
D)  Yellow and cloudy with foul odor

Question 6

A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)

Accepted Answer

A)  Less maternal fatigue 
B)  Less birth canal injuries 
C)  Decreased pushing time 
D)  Faster descent of the fetus 
E)  An increase in frequency of contractions

Question 7

Which patient at term should proceed to the hospital or birth center the immediately after labor begins?

Accepted Answer

A)  Gravida 2, para 1, who lives 10 minutes away 
B)  Gravida 1, para 0, who lives 40 minutes away 
C)  Gravida 2, para 1, whose first labor lasted 16 hours 
D)  Gravida 3, para 2, whose longest previous labor was 4 hours

Question 8

The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

Accepted Answer

A)  Every 15 minutes 
B)  Every 30 minutes 
C)  Every 45 minutes 
D)  Every 1 hour

Question 9

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?

Accepted Answer

A)  Inform the mother that the fetal heart rate is normal. 
B)  Reassess the fetal heart rate in 5 minutes because the rate is too high. 
C)  Report the fetal heart rate to the physician or nurse-midwife immediately. 
D)  Suggest to the mother that she is going to have a boy because the heart rate is fast.

Question 10

The pregnant patient expresses a desire to schedule birth during the baby's father's furlough from military service. The nurse explains that prior to induction of labor, it is essential to determine which clinical finding?

Accepted Answer

A)  Dilated cervix 
B)  Fetal lung maturity 
C)  Rupture of membranes 
D)  Uterine hypertonia

Question 11

The nurse thoroughly dries the infant immediately after birth primarily to

Accepted Answer

A)  reduce heat loss from evaporation. 
B)  stimulate crying and lung expansion. 
C)  increase blood supply to the hands and feet. 
D)  remove maternal blood from the skin surface.

Question 12

The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record?

Accepted Answer

A)  Fetal heart rate 
B)  Pain level 
C)  Test results ensuring that the fluid is not urine 
D)  The patient's understanding of the event

Question 13

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 and the hands and feet are blue. The Apgar score for this infant is

Accepted Answer

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

Question 14

The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

Accepted Answer

A)  Request a social service consult for psychosocial support. 
B)  Observe for other signs that the mother may not be accepting of the infant. 
C)  Document this evidence of normal early maternal-infant attachment behavior. 
D)  Determine whether the mother is too fatigued to interact normally with her infant.

Question 15

The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places. _____ mL

Accepted Answer

The answer of The nurse in the birth room receives...

Question 16

Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.

Accepted Answer

A)  Fluid volume deficit (FV
D)  related to fluid loss during labor and birth process 
B)  Fatigue related to length of labor requiring increased energy expenditure 
C)  Acute pain related to increased intensity of contractions 
D)  Anxiety related to imminent birth process

Question 17

A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the patient pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely

Accepted Answer

A)  a sign of abnormal labor progress. 
B)  an indication that she needs analgesia. 
C)  normal and related to hyperventilation. 
D)  common during the transition phase of labor.

Question 18

The nurse is monitoring a patient in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)

Accepted Answer

A)  Maternal hypotension 
B)  Fetal heart rate of 140 to 150 bpm 
C)  Meconium-stained amniotic fluid 
D)  Maternal fever-38°C (100.4°F) or higher 
E)  Complete uterine relaxation of more than 30 seconds between contractions

Question 19

To monitor for potential hemorrhage in the patient who has just had a cesarean birth, which action should the recovery room nurse implement?

Accepted Answer

A)  Monitor her urinary output. 
B)  Maintain an intravenous infusion at 1 mL/hour. 
C)  Assess the abdominal dressings for drainage. 
D)  Assess the uterus for firmness every 15 minutes.

Question 20

Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.)

Accepted Answer

A)  Fetal death 
B)  Postterm pregnancy 
C)  Rupture of membranes at or near term 
D)  Convenience of the patient or her health care provider 
E)  Chorioamnionitis (inflammation of the amniotic sac)

Exam 15: Nursing Care During Labor and Birth