Chapter 19: Nursing Care of the Family During Labor and Birth Lowdermilk: Maternity & Women’s Health Care, 11th Edition

TEST BANK FOR MATERNITY & WOMEN’S HEALTH CARE 11TH EDITION BY LOWDERMILK Chapter 19: Nursing Care of the Family During Labor and Birth Lowdermilk: Maternity & Women’s Health Care, 11th Edition MULTIPLE CHOICE 1. Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor? 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.‖ CORRECT ANSWER: C Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor. DIF: Cognitive Level: Understand REF: p. 431 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. When a nulliparous woman telephones the hospital to report that she is in labor, what guidance should the nurse provide or information should the nurse obtain? 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. CORRECT ANSWER: 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. 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 client may be instructed to stay home until the uterine contractions become strong and regular. Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview. 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 client or her primary health care provider. DIF: Cognitive Level: Apply REF: p. 434 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication? a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension CORRECT ANSWER: A When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of the contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension. DIF: Cognitive Level: Apply REF: p. 444 TOP: Nursing Process: Planning | Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 4. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next? a. Immediately notify the woman‘s primary health care provider. 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. CORRECT ANSWER: 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 documents these findings in the client‘s medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the trCORRECT ANSWERition phase of the first stage of labor. The trCORRECT ANSWERition phase precedes the second stage of labor, or delivery of the fetus. DIF: Cognitive Level: Apply REF: p. 436 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips b. Determining the frequency by timing from the end of one contraction to the end of the next contraction c. Evaluating the intensity by pressing the fingertips into the uterine fundus d. Assessing uterine contractions every 30 minutes throughout the first stage of labor CORRECT ANSWER: C The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus, which may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses, this assessment is performed more frequently. DIF: Cognitive Level: Apply REF: pp. 440-441 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective? a. Dilation of the cervix b. Descent of the fetus to –2 station c. Rupture of the amniotic membranes d. Increase in bloody show CORRECT ANSWER: 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. Engagement and descent of the fetus are not synonymous and may occur before labor. ROM may occur with or without the presence of labor. Bloody show may indicate a slow, progressive cervical change (e.g., effacement) in both true and false labor. DIF: Cognitive Level: Understand REF: p. 431 TOP: Nursing Process: Assessment | Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance