Question 1

Which is correct for the nurse to do when preforming vaginal examinations to assess a woman's progress in labour?

Accepted Answer

The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider.A vaginal examination should be performed only when indicated by the status of the woman and her fetus.The woman should be positioned to avoid supine hypotension.The examiner should wear a sterile glove while performing a vaginal examination for a labouring woman.

Question 2

A pregnant woman is in her third trimester.She asks the nurse to explain how she can tell true labour from false labour.What should the nurse tell her about true labour contractions?

Accepted Answer

True labour contractions become more intense with walking.False labour contractions often stop with walking or position changes.Rupture of membranes may occur before or during labour.True labour contractions are regular.

Question 3

Why would the nurse expect to administer an oxytocic to a woman after expulsion of her placenta?

Accepted Answer

Oxytocics stimulate uterine contractions,which reduce blood loss after the third stage of labour.Oxytocics are not used to treat pain or prevent infection.They cause the uterus to contract,which reduces blood loss.Oxytocics do not facilitate rest and relaxation.

Question 4

When assessing a multiparous woman who has just given birth to a 2500 g boy,the nurse notes that the woman's fundus is firm and has become globular in shape.A gush of dark red blood comes from her vagina.What do these findings indicate to the nurse?

Accepted Answer

Placental separation is indicated by a firmly contracting uterus,a change in the uterus from a discoid to a globular ovoid shape,a sudden gush of dark red blood from the introitus,an apparent lengthening of the umbilical cord,and a finding of vaginal fullness.Cervical tears that do not extend to the vagina result in minimal blood loss.Signs of hemorrhage are a boggy uterus,bright red vaginal bleeding,alterations in vital signs,pallor,lightheadedness,restlessness,decreased urinary output,and alteration in the level of consciousness.If clots have formed in the upper uterine segment,the nurse would expect to find the uterus boggy and displaced to the side.

Question 5

When planning care for a labouring woman whose membranes have ruptured,the nurse recognizes that the woman's risk for which has increased?

Accepted Answer

When the membranes rupture,microorganisms from the vagina can ascend into the amniotic sac,causing chorioamnionitis and placentitis.Rupture of membranes (ROM)is not associated with fetal or maternal bleeding.Although ROM may increase the intensity of contractions and facilitate active labour,it does not result in precipitous labour.ROM has no correlation with supine hypotension.

Question 6

The uterine contractions of a woman early in the active phase of labour are assessed by an internal uterine pressure catheter (IUPC).The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg.The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds.On the basis of this information,what should the nurse do?

Accepted Answer

The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta.In addition,the nurse would document these findings in the patient's medical record.This labour pattern indicates that the patient is in the active phase of the first stage of labour.Nothing indicates a need to notify the primary care provider at this time.Oxytocin augmentation is not needed for this labour pattern;this contraction pattern indicates adequate active labour.Her contractions eventually will become stronger,last longer,and come closer together during the transition phase of the first stage of labour.The transition phase precedes the second stage of labour,or delivery of the fetus.

Question 7

Which alerts the nurse that a woman is in true labour?

Accepted Answer

Regular,strong contractions with the presence of cervical change indicate that the woman is experiencing true labour.Loss of the mucous plug (operculum)often occurs during the first stage of labour or before the onset of labour,but it is not the indicator of true labour.Spontaneous rupture of membranes often occurs during the first stage of labour,but it is not the indicator of true labour.The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labour,but this is not the indicator of true labour.

Question 8

Through vaginal examination the nurse determines that a woman is 4 cm dilated,and the external fetal monitor shows uterine contractions every 3 1/2  to 4 minutes.How should the nurse document these findings?

Accepted Answer

The first stage,active phase of maternal progress is indicated in the assessment of this woman.During the latent phase of the first stage of labour,the expected maternal progress would be 0 to 3 cm dilation with contractions every 5 to 30 minutes.During the active phase,expected maternal progress is 4 to 10 cm dilation.During the latent and active phases of the second stage of labour,the woman is completely dilated and experiences a restful period of "labouring down."

Question 9

What would the nurse expect from a nulliparous woman who has just begun the second stage of her labour?

Accepted Answer

Common maternal behaviors during the latent phase of the second stage of labour include feeling a sense of accomplishment and optimism because the first stage is completed.During the latent phase of the second stage of labour,the urge to bear down often is absent or only slight during the acme of contractions.Perineal bulging occurs during the transition phase of the second stage of labour,not at the beginning of the second stage.An increase in bright red bloody show occurs during the descent phase of the second stage of labour.

Question 10

When a nulliparous woman telephones the hospital to report that she is in labour,what should the nurse do,initially?

Accepted Answer

Assessment begins at the first contact with the woman,whether by telephone or in person.Many hospitals discourage the nurse from giving advice regarding what to do because of legal liability.Nurses are often instructed to tell women who call with questions to call their primary health care provider or to come to the hospital if they feel the need to be checked.The amniotic membranes may or may not spontaneously rupture during labour.The patient may be instructed to stay home until the uterine contractions become strong and regular.The nurse may want to discuss the appropriate oral intake for early labour,such as light foods or clear liquids,depending on the preference of the patient or her primary health care provider.The nurse would not advise a woman who has not been assessed to stay at home until contractions are 2 to 3 minutes apart.

Question 11

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

Accepted Answer

The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips.Many women may experience labour pain in the lower segment of the uterus,which may be unrelated to the firmness of the contraction detectable in the uterine fundus.The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction.Assessment of uterine activity is performed in intervals based on the stage of labour.As labour progresses,this assessment is performed more frequently.

Question 12

A woman who is 39 weeks pregnant expresses fear about her impending labour and how she will manage.What is the basis for the nurse's response?

Accepted Answer

Basing the response on the approach that is it normal to be anxious about labour and exploring her feelings allows the woman to share her concerns with the nurse and is a therapeutic communication tool.Offering assurance that she will do fine negates the woman's fears and is not therapeutic.Confirming that labour is scary to think about,but the actual experience isn't that bad negates the woman's fears and offers a false sense of security.It is not true that every woman may have an epidural.A number of criteria must be met for use of an epidural.Furthermore,many women still experience the feeling of pressure with an epidural.

Question 13

What is an expected characteristic of amniotic fluid?

Accepted Answer

Amniotic fluid normally is a pale,straw-coloured fluid that may contain white flecks of vernix.Yellow-stained fluid may indicate fetal hypoxia 36 hours before rupture of membranes,fetal hemolytic disease,or intrauterine infection.Amniotic fluid produces an alkaline result on a Nitrazine test.The presence of ferning is a positive indication of amniotic fluid.

Question 14

When managing the care of a woman in the second stage of labour,the nurse uses various measures to enhance the progress of fetal descent.Which interventions would be appropriate at this time?

Accepted Answer

Upright position and squatting both may enhance the progress of fetal descent.Many factors dictate when a woman will begin pushing.Complete cervical dilation is necessary,but it is only one factor.If the fetal head is still in a higher pelvic station,the physician or midwife may allow the woman to "labour down" (allowing more time for fetal descent,thereby reducing the amount of pushing needed)if the woman is able.The epidural may mask the sensations and muscle control needed for the woman to push effectively.Closed-glottis breathing may trigger the Valsalva manoeuvre,which increases intrathoracic and cardiovascular pressures,reducing cardiac output and inhibiting perfusion of the uterus and placenta.In addition,holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta,resulting in fetal hypoxia.

Question 15

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

Accepted Answer

Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.Breastfeeding facilitates maternal-newborn interaction,but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth.The primary intervention for preventing neonatal hypoglycemia is thermoregulation.Cold stress can result in hypoglycemia.Breastfeeding is encouraged to initiate the lactation cycle,but it is not the primary reason for this activity after an emergency birth.

Question 16

Which would indicate that a woman has understood education related to the characteristics of true labour?

Accepted Answer

True labour contractions occur regularly,becoming stronger,lasting longer,and occurring closer together.They may become intense during walking and continue despite comfort measures.Typically,true labour contractions are felt in the lower back,radiating to the lower portion of the abdomen.During false labour,contractions tend to be irregular and felt in the abdomen above the navel.Typically,during false labour,the contractions often stop with walking or a change of position.

Question 17

What is the priority nursing action in caring for the newborn immediately after birth?

Accepted Answer

The care given immediately after the birth focuses on assessing and stabilizing the newborn.Although fostering parent-infant attachment is an important task for the nurse,it is not the most critical nursing action in caring for the newborn immediately after birth.The nursing activities would be (in order of importance)to maintain a patent airway,support respiratory effort,and prevent cold stress by drying the newborn and covering the infant with a warmed blanket or placing the newborn under a radiant warmer.After the newborn has been stabilized,the nurse assesses the newborn's physical condition,weighs and measures the newborn,administers prophylactic eye ointment and a vitamin K injection,affixes an identification bracelet,wraps the newborn in warm blankets,and then gives the infant to the partner or mother when he or she is ready.

Question 18

Which finding indicates to the nurse that the second stage of labour,the descent phase,has begun?

Accepted Answer

During the descent phase of the second stage of labour,the woman may experience an increase in the urge to bear down.Rupture of membranes has no significance in determining the stage of labour.The second stage of labour begins with full cervical dilation.Many women may have an urge to bear down when the presenting part is below the level of the ischial spines.This can occur during the first stage of labour,as early as 5-cm dilation.

Question 19

A multiparous woman has been in labour for 8 hours.Her membranes have just ruptured.What is the nurse's initial response?

Accepted Answer

The umbilical cord may prolapse when the membranes rupture.The fetal heart rate and pattern should be monitored closely for several minutes immediately after rupture of membranes (ROM)to ascertain fetal well-being,and the findings should be documented.ROM may increase the intensity and frequency of the uterine contractions,but it does not indicate that birth is imminent.The nurse may notify the primary care provider after ROM occurs and the fetal well-being and response to ROM have been assessed.The nurse's priority is to assess fetal well-being.The nurse should document the characteristics of the amniotic fluid,but the initial response is to assess fetal well-being and the response to ROM.

Question 20

When assessing a woman in the first stage of labour,the nurse recognizes that which is the most conclusive sign that uterine contractions are effective?

Accepted Answer

The vaginal examination reveals whether the woman is in true labour.Cervical change,especially dilation,in the presence of adequate labour indicates that the woman is in true labour.Descent of the fetus,or engagement,may occur before labour.Rupture of membranes may occur with or without the presence of labour.Bloody show may indicate slow,progressive cervical change (e.g. ,effacement)in both true and false labour.

Quiz 17: Nursing Care of the Family During Labour and Birth