Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
1. The nurse recognizes that a woman is in true labor when she states:
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 ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. 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 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. Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
2. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's understanding of the instructions when she states, "True labor contractions will:
a. subside when I walk around."
b. cause discomfort over the top of my uterus."
c. continue and get stronger even if I relax and take a shower."
d. remain irregular but become stronger." - Correct Answer ANS: C
True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during
walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of
the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position. Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
3. When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:
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 ANS: 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 the assessment and gather data. The amniotic membranes may or may not spontaneously rupture during labor. The patient may be instructed to stay home until the uterine contractions become strong and regular. 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 patient or her primary health care provider. Before instructing the woman to come to the Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
hospital, the nurse should initiate the assessment during the telephone interview.
4. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _________________________ has increased.
a. intrauterine infection
b. hemorrhage
c. precipitous labor
d. supine hypotension - Correct Answer ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or
maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
1. The nurse recognizes that a woman is in true labor when she states:
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 ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. 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 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. Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
2. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's understanding of the instructions when she states, "True labor contractions will:
a. subside when I walk around."
b. cause discomfort over the top of my uterus."
c. continue and get stronger even if I relax and take a shower."
d. remain irregular but become stronger." - Correct Answer ANS: C
True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during
walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of
the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position. Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
3. When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should:
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 ANS: 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 the assessment and gather data. The amniotic membranes may or may not spontaneously rupture during labor. The patient may be instructed to stay home until the uterine contractions become strong and regular. 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 patient or her primary health care provider. Before instructing the woman to come to the Chapter 16: Nursing Care of the
Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition
hospital, the nurse should initiate the assessment during the telephone interview.
4. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _________________________ has increased.
a. intrauterine infection
b. hemorrhage
c. precipitous labor
d. supine hypotension - Correct Answer ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or
maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.
