Chapter 15 Maternal and Child Health Nursing 7th Edition

Chapter 15  Maternal and Child Health Nursing 7th Edition

Complete Chapter Questions And Answers
 

Sample Questions

1.
The fetus of a patient in labor is in a vertex presentation and at a –1 station. How should the nurse interpret the location of the fetal head?
A)
Floating
B)
Engaged
C)
Crowning
D)
At the ischial spines
Ans:
A

Feedback:

Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. The degree of engagement is established by vaginal and cervical examination. Station refers to the relationship of the presenting part of the fetus to the level of the ischial spines. If the presenting part is above the spines, the distance is measured and described as minus stations, such as –1. The fetal head is currently floating. The head would be engaged if it were at the level of the ischial spines. Crowning is when the top of the fetal head is visible and birth is imminent.

2.
When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture?
A)
Meconium-stained amniotic fluid
B)
Fetus presenting in an LOA position
C)
Maternal pulse of 90 to 95 beats/min
D)
Blood-tinged vaginal discharge at full dilation
Ans:
A

Feedback:

Meconium staining means that the fetus has lost rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. The fetal presentation is not assessed during membrane rupture. The maternal pulse rate of 90 to 95 beats/min is expected during labor. Blood-tinged vaginal discharge at full dilation is an expected finding.

3.
The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? (Select all that apply.)
A)
False labor contractions are irregular.
B)
True labor contractions disappear when asleep.
C)
False labor contractions lead to cervical dilation.
D)
True labor contractions occur in the abdomen and groin.
E)
False labor contractions do not increase in duration, frequency, and intensity.
Ans:
A, E

Feedback:

False labor contractions are irregular. True labor contractions increase in duration, frequency, and intensity. False labor contractions disappear when asleep and occur in the abdomen and groin. True labor contractions lead to cervical dilation.

4.
The nurse is preparing to assess the frequency of contractions for a patient in labor. Which process should the nurse use to time the contractions?
A)
Number of contractions that occur in 5 minutes
B)
The end of one contraction to the beginning of the next
C)
The interval between the acmes of two consecutive contractions
D)
The interval between the beginning and the end of one contraction
Ans:
D

Feedback:

To determine the beginning of a contraction without a monitor, rest a hand on a woman’s abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. Contractions are not timed by measuring the number of contractions in 5 minutes, the end of one contraction to the beginning of the next, or by using the interval between the acmes of two consecutive contractions.

5.
After pelvic measurements, a patient who is 20 weeks pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address?
A)
Powers
B)
Passage
C)
Passenger
D)
Psychological outlook
Ans:
B

Feedback:

Passage focuses on the size and contour of the pregnant patient’s pelvis. Passenger addresses the size, position, and presentation of the fetus. Powers determine if uterine factors for labor are adequate. Psychological outlook focuses on the pregnant patient’s ability to view labor as a positive experience.