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Ch 16 Giving Birth Questions
Terms in this set (42)
1. The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products
c. Diminishes as the spiral arteries are compressed
(During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle.)
2. Which statement is the best rationale for assessing maternal vital signs between contractions?
b. Maternal circulating blood volume increases temporarily during contractions.
(During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows pulse.)
3. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
(Engagement occurs when the presenting part fully enters the pelvic inlet.)
4. To adequately care for patients, the nurse understands that labor contractions facilitate cervical dilation by
d. Pulling the cervix over the fetus and amniotic sac
(Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward.)
5. It is important for the nurse providing care during labor to be aware that pregnant women can usually tolerate the normal blood loss associated with childbirth because they have
b. Increased blood volume
(Women have a significant increase in blood volume during pregnancy. After delivery, the additional circulating volume is no longer necessary.)
6. To assess the duration of labor contractions, the nurse determines the time
b. From the beginning to the end of each contraction
(Duration of labor contractions is the average length of contractions from beginning to end.)
7. To adequately teach patients about the process of labor, the nurse knows that which event is the best indicator of true labor?
b. Cervical dilation and effacement
(The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix.)
8. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?
(Flexion of the fetal head allows the smallest head diameters pass through the pelvis.)
9. What results from the adaptation of the fetus to the size and shape of the pelvis?
(The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis.)
10. A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor?
b. Active phase
11. To teach and support the woman in labor, the nurse explains that the strongest part of a labor contraction is the
(The acme is the peak or period of greatest strength during the middle of a contraction cycle.)
12. What occurrence is associated with cervical dilation and effacement?
a. Bloody show
(As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries.)
13. To be aware of potential risks to the laboring woman, the nurse understands that a breech presentation is associated with
a. Umbilical cord compression
( The umbilical cord can be compressed between the fetal body and the maternal pelvis when the body has been born but the head remains within the pelvis.)
14. The primary difference between the labor of a nullipara and that of a multipara is the
b. Total duration of labor
(Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter.)
15. Which maternal factor may inhibit fetal descent and require further nursing interventions?
b. A full bladder
(A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part.)
16. Leopold's maneuvers are used by practitioners to determine
a. The best location to assess the fetal heart rate (FHR)
(Leopold's maneuvers are often performed before assessing the FHR. These maneuvers help identify the best location to obtain the FHR.)
17. Which comfort measure should the nurse use to assist the laboring woman to relax?
d. Recommend frequent position changes.
(Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent.)
18. Which assessment finding could indicate hemorrhage in the postpartum patient?
d. Elevated pulse rate
(An increasing pulse rate is an early sign of excessive blood loss.)
19. What is an essential part of nursing care for the laboring woman?
a. Helping the woman manage the pain.
(Helping a woman manage the pain is an essential part of nursing care, because pain is an expected part of normal labor and cannot be fully relieved.)
20. A woman at 40 weeks of gestation should be instructed to go to a hospital or birth center for evaluation when she experiences
a. A trickle of fluid from the vagina
(A trickle of fluid from the vagina may indicate rupture of the membranes requiring evaluation for infection or cord compression.)
21. Which patient at term should go to the hospital or birth center the soonest after labor begins?
c. Gravida 3 para 2 whose longest previous labor was 4 hours
(Multiparous women usually have shorter labors than do nulliparous women. The woman described in option c is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances.)
22. A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are
b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth
(All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner.)
23. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be
d. Discharged home to await the onset of true labor
The situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins.
24. The nurse auscultates the fetal heart rate (FHR) and determines a rate of 152. Which nursing intervention is appropriate?
a. Inform the mother that the rate is normal.
(The FHR is within the normal range, so no other action is indicated at this time.)
25. A laboring woman is lying in the supine position. The most appropriate nursing action is to
a. Ask her to turn to one side.
26. What finding should the nurse recognize as being associated with fetal compromise?
d. Meconium-stained amniotic fluid
(When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid.)
27. During the active phase of labor, the FHR of a low-risk patient should be assessed every
b. 30 minutes
(For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor.)
28. Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?
c. The vulva bulges and encircles the fetal head.
(A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth.)
29. During labor, a vaginal examination should be performed only when necessary because of the risk of
(Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus.)
30. A 25-year-old primigravida is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly the woman pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely
b. Common during the transition phase of labor
The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability.
31. 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, but the hands and feet are blue. What is the Apgar score for this infant?
(The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet.)
32. If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to
b. Massage the fundus.
(The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss.)
33. The nurse thoroughly dries the infant immediately after birth primarily to
c. Reduce heat loss from evaporation.
(Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss.)
34. The nurse notes that a woman who has given birth 1 hour ago is touching her infant with the fingertips and talking to him softly in high-pitched tones. On the basis of this observation, the nurse should
a. Document this evidence of normal early maternal-infant attachment behavior.
(Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant.)
35. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, 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 likely position of the fetus?
c. RSA (Right sacral anterior)
36. To adequately care for a laboring woman, the nurse should know that the _____ stage of labor varies the most in length.
(The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined.)
37. A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate "labor is getting closer to starting." The nurse informs the woman that which of the following is a sign that labor may begin soon?
d. Surge of energy
Women speak of having a burst of energy before labor.
38. At hand-off report the off-going nurse states that the patient demonstrated clonus on her last assessment. What action by the on-coming nurse takes priority?
b. Institute seizure precautions.
39. The labor and delivery nurse is evaluating a newly admitted woman's lab and notes a hemoglobin of 9.1 mg/dL and hematocrit of 31%. What action by the nurse takes priority?
c. Assess for response to blood loss during and after birth.
(The normal values for a woman about to deliver are 10.5 mg/dL and 33%. Values lower than this indicate the maternal reserves may not be adequate for the normal blood loss in delivery. It's like a mountain 10.5, 11, 10.5, first, second and third trimester hemoglobin levels)
1. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the "four Ps." These are the four major factors that interact during normal childbirth. What are the "four Ps"?
1. Inquiring about past pregnancies is an important part of the nursing assessment. Women who have had a previous cesarean birth may request a trial of labor and a ______ delivery.
VBAC [vaginal birth after cesarean]
(Although vaginal birth after cesarean is less common, it may be chosen for a variety of reasons. The nurse should be aware of the need for increased support of the woman in labor, and for complications that may occur.)
2. A woman who is gravida 3 para 2 enters the intrapartum unit. Which nursing assessments take priority at this time? (Select all that apply.)
a. Fetal heart rate
b. Maternal vital signs
c. The woman's nearness to birth
THIS SET IS OFTEN IN FOLDERS WITH...
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