Chapter 16 Labor and Birth Processes

Chapter 16  Labor and Birth Processes

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. What is the nurse’s best response, based upon her understanding of when the anterior frontal closes?
a.
2 months
b.
8 months
c.
12 months
d.
18 months

ANS: D
The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. The posterior fontanel closes at 6 to 8 weeks. The remaining three options are too early for the anterior fontanel to close.

DIF: Cognitive Level: Understand REF: p. 367
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

2. The nurse is performing an initial assessment of a client in labor. What is the appropriate terminology for the relationship of the fetal body parts to one another?
a.
Lie
b.
Presentation
c.
Attitude
d.
Position

ANS: C
Attitude is the relationship of the fetal body parts to one another. Lie is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother’s pelvis.

DIF: Cognitive Level: Remember REF: p. 369
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. When assessing the fetus using Leopold’s maneuvers, the nurse feels a round, firm, and movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother’s right side close to midline. What is the position of the fetus?
a.
ROA
b.
LSP
c.
RSA
d.
LOA

ANS: C
Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or the left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relationship to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother’s right side denotes the location of the presenting part in the mother’s pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is anteriorly positioned in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is anteriorly positioned in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is posteriorly positioned in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be anteriorly positioned in the left side of the pelvis with the occiput as the presenting part.

DIF: Cognitive Level: Apply REF: p. 370
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. Which statement by the client would lead the nurse to believe that labor has been established?
a.
“I passed some thick, pink mucus when I urinated this morning.”
b.
“My bag of waters just broke.”
c.
“The contractions in my uterus are getting stronger and closer together.”
d.
“My baby dropped, and I have to urinate more frequently now.”

ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Although the loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor; however, it is not an indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor but is not the indicator of true labor.

DIF: Cognitive Level: Understand REF: p. 376
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?
a.
Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
b.
Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
c.
Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
d.
Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

ANS: B
The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. The first interpretation of this vaginal examination is incorrect; the cervix is dilated 3 cm and is 30% effaced. However, the presenting part is correct at 2 cm above the ischial spines. The remaining two interpretations of this vaginal examination are incorrect. Although the dilation and effacement are correct at 3 cm and 30%, the presenting part is actually 2 cm above the ischial spines.

DIF: Cognitive Level: Comprehend REF: p. 370 | pp. 373-374
TOP: Nursing Process: Assessment | Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance