NUR410 MATERNITY Chapter 16: Labor and Delivery Comprehensive Questions and Answers 100% Accuracy

The Maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products a. Continues except when placental functions are reduced b. Increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Is not significantly affected - ANS ANS: C Feedback A The maternal blood supply to the placenta gradually stops with contractions. B The exchange of oxygen and waste products decreases. C 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. D The exchange of oxygen and waste products is affected by contractions. Which statement is the best rationale for assessing maternal vital signs between contractions? a. During a contraction, assessing fetal heart rates is the priority. b. Maternal circulating blood volume increases temporarily during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate. - ANS ANS: B Feedback A It is important to monitor fetal response to contractions, but the question is concerned with the maternal vital signs. B 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. C Maternal blood flow is increased during a contraction. D Vital signs are altered by contractions but are considered accurate for that period of time. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Engagement b. Extension c. Internal rotation d. External rotation - ANS ANS: A Feedback A Engagement occurs when the presenting part fully enters the pelvic inlet. B Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. C Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. D External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet. To adequately care for patients, the nurse understands that labor contractions facilitate cervical dilation by a. Contracting the lower uterine segment b. Enlarging the internal size of the uterus c. Promoting blood flow to the cervix d. Pulling the cervix over the fetus and amniotic sac - ANS ANS: D Feedback A The contractions are stronger at the fundus. B The internal size becomes smaller with the contractions; this helps to push the fetus down. C Blood flow decreases to the uterus during a contraction. D Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward. 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 a. A higher hematocrit b. Increased blood volume c. A lower fibrinogen level d. Increased leukocytes - ANS ANS: B Feedback A The hematocrit decreases with pregnancy due to the high fluid volume. B Women have a significant increase in blood volume during pregnancy. After delivery, the additional circulating volume is no longer necessary. C Fibrinogen levels increase with pregnancy. D Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. To assess the duration of labor contractions, the nurse determines the time a. From the beginning of one contraction to the beginning of the next b. From the beginning to the end of each contraction c. Of the strongest intensity of each contraction d. Of uterine relaxation between two contractions - ANS ANS: B Feedback A This is the frequency of the contractions. B Duration of labor contractions is the average length of contractions from beginning to end. C This is the strength or intensity of the contractions. D This is the interval of the contraction phase. To adequately teach patients about the process of labor, the nurse knows that which event is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes - ANS ANS: B Feedback A Bloody show can occur before true labor. B The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. C Fetal descent can occur before true labor. D False labor may have contractions that occur this frequently, but it is usually inconsistent. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Descent b. Engagement c. Flexion d. Station - ANS ANS: C Feedback A Descent is the moving of the fetus through the birth canal. B Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic inlet. C Flexion of the fetal head allows the smallest head diameters pass through the pelvis. D The station is the relationship of the fetal presenting part to the level of the ischial spines. What results from the adaptation of the fetus to the size and shape of the pelvis? a. Lightening b. Lie c. Molding d. Presentation - ANS ANS: C Feedback A Lightening is the descent of the fetus toward the pelvic inlet before labor. B Lie is the relationship of the long axis of the fetus to the long axis of the mother. C 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. D Presentation is the fetal part that first enters the pelvic inlet. A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage - ANS ANS: B Feedback A The latent phase is from the beginning of true labor until 3 cm of cervical dilation. B The active phase of labor is characterized by cervical dilation of 4 to 7 cm. C The second stage of labor begins when the cervix is completely dilated until the birth of the baby. D The third stage of labor is from the birth of the baby until the expulsion of the placenta. To teach and support the woman in labor, the nurse explains that the strongest part of a labor contraction is the a. Increment b. Acme c. Decrement d. Interval - ANS ANS: B Feedback A The increment is the beginning of the contractions until it reaches the peak. B The acme is the peak or period of greatest strength during the middle of a contraction cycle. C The decrement occurs after the peak until the contraction ends. D The interval is the period between the end of the contraction and the beginning of the next. What occurrence is associated with cervical dilation and effacement? a. Bloody show b. False labor c. Lightening d. Bladder distention - ANS ANS: A Feedback A 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. B Cervical dilation and effacement do not occur with false labor. C Lightening is the descent of the fetus toward the pelvic inlet before labor. D Bladder distention occurs when the bladder is not empted frequently. It may slow down the decent of the fetus during labor. To be aware of potential risks to the laboring woman, the nurse understands that a breech presentation is associated with a. Umbilical cord compression b. More rapid labor c. A high risk of infection d. Maternal perineal trauma - ANS ANS: A Feedback A 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. B Breech presentation is not associated with a more rapid labor. C There is no higher risk of infection with a breech birth. D There is no higher risk for perineal trauma with a breech birth. The primary difference between the labor of a nullipara and that of a multipara is the a. Amount of cervical dilation b. Total duration of labor c. Level of pain experienced d. Sequence of labor mechanisms - ANS ANS: B Feedback A Cervical dilation is the same for all labors. B Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. C Level of pain is individual to the woman, not to the number of labors she has experienced. D The sequence of labor mechanisms is the same with all labors. Which maternal factor may inhibit fetal descent and require further nursing interventions? a. Decreased peristalsis b. A full bladder c. Reduction in internal uterine size d. Rupture of membranes - ANS ANS: B Feedback A Peristalsis does not influence fetal descent. B A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. C Contractions will reduce the internal uterine size in order to assist fetal descent. D Rupture of membranes will assist in the fetal descent. Leopold's maneuvers are used by practitioners to determine a. The best location to assess the fetal heart rate (FHR) b. Cervical dilation and effacement c. Whether the fetus is in the posterior position d. The status of the membranes - ANS ANS: A Feedback A Leopold's maneuvers are often performed before assessing the FHR. These maneuvers help identify the best location to obtain the FHR. B Dilation and effacement are best determined by vaginal examination. C Assessment of fetal position is more accurate with vaginal examination. D A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Which comfort measure should the nurse use to assist the laboring woman to relax? a. Keep the room lights lit so that the patient and her coach can see everything. b. Offer warm, wet cloths to use on the patient's face and neck. c. Palpate her filling bladder every 15 minutes. d. Recommend frequent position changes. - ANS ANS: D Feedback A Soft, indirect lighting is more soothing than irritating bright lights. B Women in labor become hot and perspire. Cool cloths are much better C A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. D Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. Which assessment finding could indicate hemorrhage in the postpartum patient? a. Firm fundus at the midline b. Saturation of two perineal pads in 4 hours c. Elevated blood pressure d. Elevated pulse rate - ANS ANS: D Feedback A A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. B 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. C If the blood volume were diminishing, the blood pressure would decrease. D An increasing pulse rate is an early sign of excessive blood loss. What is an essential part of nursing care for the laboring woman? a. Helping the woman manage the pain. b. Eliminating the pain associated with labor. c. Sharing personal experiences regarding labor and delivery to decrease her anxiety. d. Feeling comfortable with the predictable nature of intrapartal care. - ANS ANS: A Feedback A 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. B Labor pain cannot be fully relieved. C Decreasing anxiety is important, but managing pain is a top priority. D The labor nurse should always be assessing for unpredictable occurrences. 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 b. Thick pink or dark red vaginal mucus c. Irregular contractions for 1 hour d. Fetal movement - ANS ANS: A Feedback A A trickle of fluid from the vagina may indicate rupture of the membranes requiring evaluation for infection or cord compression. B Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced. C This is a sign of false labor and does not require further assessment. D The lack of fetal movement needs further assessment. Which patient at term should go to the hospital or birth center the soonest 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 3 para 2 whose longest previous labor was 4 hours d. Gravida 2 para 1 whose first labor lasted 16 hours - ANS ANS: C Feedback A A gravida 2 is expected to have a longer labor than the gravida 3. The fact that she lives close to the hospital allows her to stay home for a longer period of time. B A gravida 1 is expected to have the longest labor. C 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. D The gravida 2 is expected to have a longer labor than the gravida 3, especially since her first labor was 16 hours. A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are a. Contraction pattern, amount of discomfort, and pregnancy history b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth c. Identification of ruptured membranes, the woman's gravida and para, and her support person d. Last food intake, when labor began, and cultural practices the couple desires - ANS ANS: B Feedback A This is an important nursing assessment, but does not take priority if the birth is imminent. 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. C This is an assessment that can occur later in the admission process if time permits. D This part of the assessment can occur later in the admission process if time permits. 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 a. Admitted and prepared for a cesarean birth b. Admitted for extended observation c. Discharged home with a sedative d. Discharged home to await the onset of true labor - ANS ANS: D Feedback A These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated. B These are all indications of false labor; there is no indication that further assessment or observations are indicated. C The patient will probably be discharged, but there is no indication that a sedative is needed. D The situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. 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. b. Reassess the FHR in 5 minutes because the rate is too high. c. Report the FHR to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast. - ANS ANS: A Feedback A The FHR is within the normal range, so no other action is indicated at this time. B The FHR is within the expected range; reassessment should occur, but not in 5 minutes. C The FHR is within the expected range; no further action is necessary at this point. D The sex of the baby cannot be determined by the FHR. A laboring woman is lying in the supine position. The most appropriate nursing action is to a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine if fetal tachycardia is present. - ANS ANS: A Feedback A The woman's supine position may cause the heavy uterus to compress her inferior vena cava, reducing blood return to her heart and reducing placental blood flow. This problem is relieved by having her turn onto her side. B Elevating her legs will not relieve the pressure from the inferior vena cava. C This position may produce hypotension in the woman, but the action should be to prevent this from happening, not to assess for the problem. D If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side. What finding should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Contractions lasting 90 seconds c. FHR in the 140s d. Meconium-stained amniotic fluid - ANS ANS: D Feedback A Active fetal movement is an expected occurrence. B The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. C Expected FHR range is from 120 to 160. D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. During the active phase of labor, the FHR of a low-risk patient should be assessed every a. 15 minutes b. 30 minutes c. 45 minutes d. 1 hour - ANS ANS: B Feedback A 15-minute assessments are appropriate for a fetus at high risk. B 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. C 45-minute assessments during the active phase of labor is not frequent enough to monitor for complications. D 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications. Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction. - ANS ANS: C Feedback A Birth of the head occurs when the station is +4. A 0 station indicates engagement. B Bloody show occurs throughout the labor process and is not an indication of an imminent birth. C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. D Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.