CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH
FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING,
7TH EDITION
1. The nurse is preparing to perform Leopold’s maneuvers. Please select the rationale for
the consistent use of these maneuvers by obstetric providers?
a.
To determine the status of the membranes
b.
To determine cervical dilation and effacement
c.
To determine the best location to assess the fetal heart rate
d.
To determine whether the fetus is in the posterior position
ANS: C
Leopold’s maneuvers are often performed before assessing the fetal heart rate (FHR).
These maneuvers help identify the best location to obtain the FHR. A pH test or fern test
can be performed to determine the status of the fetal membranes. Dilation and effacement
are best determined by vaginal examination. Assessment of fetal position is more accurate
with vaginal examination.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
a.
Recommend frequent position changes.
b.
Palpate her filling bladder every 15 minutes.
c.
Offer warm wet cloths to use on the patient’s face and neck.
d.
Keep the room can see everything.
ANS: A
Frequent maternal position changes reduce the discomfort from constant pressure and promote
fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2
hours. Women in labor become very hot and perspire. Cool cloths will provide greater relief.
Soft indirect lighting is more soothing than irritating bright lights.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. Which assessment finding is an indication of hemorrhage in the recently delivered
postpartum patient?
a.
Elevated pulse rate
b.
Elevated blood pressure
c.
Firm fundus at the midline
d.
Saturation of two perineal pads in 4 hours
ANS: A
An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were
diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is
contracting and compressing the open blood vessels at the placental site. Saturation of one pad
within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours
is within normal limits.
, CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH
FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING,
7TH EDITION
DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which intervention is an essential part of nursing care for a laboring patient?
a.
Helping the woman manage the pain
b.
Eliminating the pain associated with labor
c.
Feeling comfortable with the predictable nature of intrapartal care
d.
Sharing personal experiences regarding labor and birth to decrease her anxiety
ANS: A
Helping a patient manage the pain is an essential part of nursing care because pain is
an expected part of normal labor and cannot be fully relieved. Labor pain cannot be
fully relieved. The labor nurse should always be assessing for unpredictable
occurrences.
Decreasing anxiety is important; however, managing pain is a top priority.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
5. A patient at 40 weeks’ gestation should be instructed to go to a hospital or birth center for
evaluation when she experiences
a.
increased fetal movement.
b.
irregular contractions for 1 hour.
c.
a trickle of fluid from the vagina.
d.
thick pink or dark red vaginal mucus.
ANS: C
assessment. Irregular contractions are a sign of false labor and do not require further
assessment. Bloody show may occur before the onset of true labor. It does not
require professional assessment unless the bleeding is pronounced.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
6. Which patient at term should proceed to the hospital or birth center the immediately
after labor begins?
a.
Gravida 2, para 1, who lives 10 minutes away
b.
Gravida 1, para 0, who lives 40 minutes away
c.
Gravida 2, para 1, whose first labor lasted 16 hours
d.
Gravida 3, para 2, whose longest previous labor was 4 hours
ANS: D
Multiparous women usually have shorter labors than do nulliparous women. The woman
described in option D is multiparous with a history of rapid labors, increasing the likelihood
that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to
have a longer labor than the gravida in option C. The fact that she lives close to the hospital
allows her to stay home for a longer period of time. A gravida 1 will be expected to have the
longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3,
especially because her first labor was 16 hours.
, CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH
FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING,
7TH EDITION
DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
7. A woman who is gravida 3, para 2 enters the intrapartum unit. The most important
nursing assessments include
a.
contraction pattern, amount of discomfort, and pregnancy history.
b.
fetal heart rate, maternal vital signs, and the woman’s nearness to birth.
c.
last food intake, when labor began, and cultural practices the couple desires.
d.
identification of ruptured membranes, the woman’s gravida and para, and access
to a support person.
ANS: B
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. Contraction pattern, amount of
discomfort, and pregnancy history are important nursing assessments but do not take priority
if the birth is imminent. Last food intake, when labor began, and cultural practices the
couple desires is an assessment that can occur later in the admission process, if time permits.
Identification of ruptured membranes, the woman’s gravida and para, and her support
person are assessments that can occur later in the admission process if time permits.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. 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 the patient to be
a.
discharged home with a sedative.
b.
admitted for extended observation.
c.
admitted and prepared for a cesarean birth.
d.
discharged home to await the onset of true labor.
ANS: D
The situation describes a patient with normal assessments who is probably in false labor and
will probably not deliver rapidly once true labor begins. The patient will probably be
discharged, and there is no indication that a sedative is needed. These are all indications of
false labor; there is no indication that further assessment or observations are indicated. These
are all indications of false labor without fetal distress. There is no indication that a cesarean
birth is indicated.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which
nursing intervention is most appropriate at this time?
a.
Inform the mother that the fetal heart rate is normal.
b.
Reassess the fetal heart rate in 5 minutes because the rate is too high.
c.
Report the fetal heart rate to the physician or nurse-midwife immediately.
d.
Suggest to the mother that she is going to have a boy because the heart rate is fast.
FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING,
7TH EDITION
1. The nurse is preparing to perform Leopold’s maneuvers. Please select the rationale for
the consistent use of these maneuvers by obstetric providers?
a.
To determine the status of the membranes
b.
To determine cervical dilation and effacement
c.
To determine the best location to assess the fetal heart rate
d.
To determine whether the fetus is in the posterior position
ANS: C
Leopold’s maneuvers are often performed before assessing the fetal heart rate (FHR).
These maneuvers help identify the best location to obtain the FHR. A pH test or fern test
can be performed to determine the status of the fetal membranes. Dilation and effacement
are best determined by vaginal examination. Assessment of fetal position is more accurate
with vaginal examination.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
2. Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?
a.
Recommend frequent position changes.
b.
Palpate her filling bladder every 15 minutes.
c.
Offer warm wet cloths to use on the patient’s face and neck.
d.
Keep the room can see everything.
ANS: A
Frequent maternal position changes reduce the discomfort from constant pressure and promote
fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2
hours. Women in labor become very hot and perspire. Cool cloths will provide greater relief.
Soft indirect lighting is more soothing than irritating bright lights.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
3. Which assessment finding is an indication of hemorrhage in the recently delivered
postpartum patient?
a.
Elevated pulse rate
b.
Elevated blood pressure
c.
Firm fundus at the midline
d.
Saturation of two perineal pads in 4 hours
ANS: A
An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were
diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is
contracting and compressing the open blood vessels at the placental site. Saturation of one pad
within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours
is within normal limits.
, CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH
FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING,
7TH EDITION
DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
4. Which intervention is an essential part of nursing care for a laboring patient?
a.
Helping the woman manage the pain
b.
Eliminating the pain associated with labor
c.
Feeling comfortable with the predictable nature of intrapartal care
d.
Sharing personal experiences regarding labor and birth to decrease her anxiety
ANS: A
Helping a patient manage the pain is an essential part of nursing care because pain is
an expected part of normal labor and cannot be fully relieved. Labor pain cannot be
fully relieved. The labor nurse should always be assessing for unpredictable
occurrences.
Decreasing anxiety is important; however, managing pain is a top priority.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Planning
MSC: Patient Needs: Health Promotion and Maintenance
5. A patient at 40 weeks’ gestation should be instructed to go to a hospital or birth center for
evaluation when she experiences
a.
increased fetal movement.
b.
irregular contractions for 1 hour.
c.
a trickle of fluid from the vagina.
d.
thick pink or dark red vaginal mucus.
ANS: C
assessment. Irregular contractions are a sign of false labor and do not require further
assessment. Bloody show may occur before the onset of true labor. It does not
require professional assessment unless the bleeding is pronounced.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Implementation
MSC: Patient Needs: Physiologic Integrity
6. Which patient at term should proceed to the hospital or birth center the immediately
after labor begins?
a.
Gravida 2, para 1, who lives 10 minutes away
b.
Gravida 1, para 0, who lives 40 minutes away
c.
Gravida 2, para 1, whose first labor lasted 16 hours
d.
Gravida 3, para 2, whose longest previous labor was 4 hours
ANS: D
Multiparous women usually have shorter labors than do nulliparous women. The woman
described in option D is multiparous with a history of rapid labors, increasing the likelihood
that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to
have a longer labor than the gravida in option C. The fact that she lives close to the hospital
allows her to stay home for a longer period of time. A gravida 1 will be expected to have the
longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3,
especially because her first labor was 16 hours.
, CHAPTER 15: NURSING CARE DURING LABOR AND BIRTH
FOUNDATIONS OF MATERNAL-NEWBORN & WOMEN’S HEALTH NURSING,
7TH EDITION
DIF: Cognitive Level: Analysis OBJ: Nursing Process Step: Evaluation
MSC: Patient Needs: Safe and Effective Care Environment
7. A woman who is gravida 3, para 2 enters the intrapartum unit. The most important
nursing assessments include
a.
contraction pattern, amount of discomfort, and pregnancy history.
b.
fetal heart rate, maternal vital signs, and the woman’s nearness to birth.
c.
last food intake, when labor began, and cultural practices the couple desires.
d.
identification of ruptured membranes, the woman’s gravida and para, and access
to a support person.
ANS: B
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. Contraction pattern, amount of
discomfort, and pregnancy history are important nursing assessments but do not take priority
if the birth is imminent. Last food intake, when labor began, and cultural practices the
couple desires is an assessment that can occur later in the admission process, if time permits.
Identification of ruptured membranes, the woman’s gravida and para, and her support
person are assessments that can occur later in the admission process if time permits.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Physiologic Integrity
8. 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 the patient to be
a.
discharged home with a sedative.
b.
admitted for extended observation.
c.
admitted and prepared for a cesarean birth.
d.
discharged home to await the onset of true labor.
ANS: D
The situation describes a patient with normal assessments who is probably in false labor and
will probably not deliver rapidly once true labor begins. The patient will probably be
discharged, and there is no indication that a sedative is needed. These are all indications of
false labor; there is no indication that further assessment or observations are indicated. These
are all indications of false labor without fetal distress. There is no indication that a cesarean
birth is indicated.
DIF: Cognitive Level: Application OBJ: Nursing Process Step: Assessment
MSC: Patient Needs: Health Promotion and Maintenance
9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which
nursing intervention is most appropriate at this time?
a.
Inform the mother that the fetal heart rate is normal.
b.
Reassess the fetal heart rate in 5 minutes because the rate is too high.
c.
Report the fetal heart rate to the physician or nurse-midwife immediately.
d.
Suggest to the mother that she is going to have a boy because the heart rate is fast.
