Chapter 12 Nursing Care of the Family during Labor and Birth

Chapter 12  Nursing Care of the Family during Labor and Birth

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates that the woman understands the instructions when she states:
a.
“True labor contractions will subside when I walk around.”
b.
“True labor contractions will cause discomfort over the top of my uterus.”
c.
“True labor contractions will continue and get stronger even if I relax and take a shower.”
d.
“True labor contractions will remain irregular but become stronger.”

ANS: C

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

DIF: Cognitive Level: Application REF: 338
OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation

2. When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:
a.
Tell the woman to stay home until her membranes rupture.
b.
Emphasize that food and fluid intake should stop.
c.
Arrange for the woman to come to the hospital for labor evaluation.
d.
Ask the woman to describe why she believes she is in labor.

ANS: D

Feedback
A
The initial nursing activity should be to gather data about the woman’s status. The amniotic membranes may or may not spontaneously rupture during labor. The woman may be instructed to stay home until the uterine contractions become strong and regular.
B
The initial nursing activity should be to gather data about the woman’s status. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor such as light foods or clear liquids, depending on the preference of the woman or her primary health care provider.
C
Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview.
D
Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data.

DIF: Cognitive Level: Application REF: 337
OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

3. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for _____ has increased.
a.
Intrauterine infection
b.
Hemorrhage
c.
Precipitous labor
d.
Supine hypotension

ANS: A

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

DIF: Cognitive Level: Comprehension REF: 352
OBJ: Client Needs: Physiologic Integrity
TOP: Nursing Process: Planning, Diagnosis

4. The uterine contractions of a woman early in the active phase of labor 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, the nurse should:
a.
Notify the woman’s primary health care provider immediately.
b.
Prepare to administer an oxytocic to stimulate uterine activity.
c.
Document the findings because they reflect the expected contraction pattern for the active phase of labor.
d.
Prepare the woman for the onset of the second stage of labor.

ANS: C

Feedback
A
Nothing indicates a need to notify the primary care provider at this time.
B
Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor.
C
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 labor pattern indicates that the woman is in the active phase of the first stage of labor.
D
This labor pattern indicates that the woman is in active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

DIF: Cognitive Level: Application REF: 352
OBJ: Client Needs: Health Promotion and Maintenance
TOP: Nursing Process: Implementation

5. 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:
a.
Dilation of the cervix.
b.
Descent of the fetus.
c.
Rupture of the amniotic membranes.
d.
Increase in bloody show.

ANS: A

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

DIF: Cognitive Level: Comprehension REF: 349
OBJ: Client Needs: Health Promotion and Maintenance
TOP: Nursing Process: Assessment, Diagnosis