C HAPTER 27: L ABOR AND D ELIVERY
Cooper: Foundation of Nursing, 9th Edition
MULTIPLE CHOICE
1. The patient’s membranes have just ruptured. What is the first priorit y of
the nurse?
a. Turn the patient on the left side.
b. Perform a Nitrazine test.
c. Check the fetal heart rate (FHR).
d. Perform a vaginal examination.
ANS: C
The FHR should be assessed immediatel y after rupture of the
membranes to determine the well -being of the baby.
DIF: Cognitive Level: Application REF: p. 816 OBJ: 10
TOP: Ruptured membranes KEY: Nursing Process
Step: Implementation MSC: NC LEX: Health Promotion
and Maintenance
2. A patient arrives at the hospital having contractions. How should the
nurse determine that the patient is in true labor?
a. There is no dilation.
b. The contractions are in t he fundus.
c. The cervix has softened and effaced.
d. The contractions are irregular.
, ANS: C
One sign of true labor is when the cervix has softened and effaced.
True labor contractions are regular and rhythmic.
DIF: Cognitive Level: Anal ysis REF: p. 799 OBJ: 4
TOP: Effacement KEY: Nursing Process Step:
Assessment MSC: NC LEX: Health Promotion and Maintenance
3. The nurse is alarmed as she assesses a protruding umbilical cord from the
vagina. What immediate action should the nurse take?
a. Monitor intensit y of contractions.
b. Place the patient in the knee -chest position.
c. Notify the charge nurse.
d. Ask the patient to perform a Valsalva’s maneuver.
ANS: B
The knee-chest position reduces the pressure on the prolapsed cord.
The charge nurse will need to be notified, a nd the contractions will
need to be monitored. However, the priority is reducing the pressure on
the prolapsed cord.
DIF: Cognitive Level: Anal ysis REF: p. 804 OBJ: 12
TOP: Cord prolapse KEY: Nursing Process Step:
Implementation MSC: NC LEX: Health Promotion and
Maintenance
, 4. A nurse is assessing the printout from the fetal monitor. What is the legal
responsibilit y of the nurse?
a. Correctl y identifying abnormal FHR patterns and prescribing
medication
b. Correctl y identifying abnormal FHR patterns and noti fying the
health care provider
c. The nurse is not legall y responsible for fetal monitoring
d. Providing technical assessment to the monitor technicians
ANS: B
Nurses are responsible for the timel y notification of the primary
caregiver in the event of an abnor mal fetal heart rate (FHR) pattern.
The nurse cannot write a medication order.
DIF: Cognitive Level: Application REF: p. 817 OBJ: 10
TOP: Fetal monitoring KEY: Nursing Process Step:
Assessment MSC: NC LEX: Health Promotion and Maintenance
5. A mother is in earl y labor and asks the nurse how long the labor will last.
The nurse explains that the first stage of labor lasts from the beginning of
regular contractions until when?
a. The cervix is completel y effaced.
b. The baby is in position.
c. The cervix is full y dilated.
d. The woman begins pushing.
ANS: C
Cooper: Foundation of Nursing, 9th Edition
MULTIPLE CHOICE
1. The patient’s membranes have just ruptured. What is the first priorit y of
the nurse?
a. Turn the patient on the left side.
b. Perform a Nitrazine test.
c. Check the fetal heart rate (FHR).
d. Perform a vaginal examination.
ANS: C
The FHR should be assessed immediatel y after rupture of the
membranes to determine the well -being of the baby.
DIF: Cognitive Level: Application REF: p. 816 OBJ: 10
TOP: Ruptured membranes KEY: Nursing Process
Step: Implementation MSC: NC LEX: Health Promotion
and Maintenance
2. A patient arrives at the hospital having contractions. How should the
nurse determine that the patient is in true labor?
a. There is no dilation.
b. The contractions are in t he fundus.
c. The cervix has softened and effaced.
d. The contractions are irregular.
, ANS: C
One sign of true labor is when the cervix has softened and effaced.
True labor contractions are regular and rhythmic.
DIF: Cognitive Level: Anal ysis REF: p. 799 OBJ: 4
TOP: Effacement KEY: Nursing Process Step:
Assessment MSC: NC LEX: Health Promotion and Maintenance
3. The nurse is alarmed as she assesses a protruding umbilical cord from the
vagina. What immediate action should the nurse take?
a. Monitor intensit y of contractions.
b. Place the patient in the knee -chest position.
c. Notify the charge nurse.
d. Ask the patient to perform a Valsalva’s maneuver.
ANS: B
The knee-chest position reduces the pressure on the prolapsed cord.
The charge nurse will need to be notified, a nd the contractions will
need to be monitored. However, the priority is reducing the pressure on
the prolapsed cord.
DIF: Cognitive Level: Anal ysis REF: p. 804 OBJ: 12
TOP: Cord prolapse KEY: Nursing Process Step:
Implementation MSC: NC LEX: Health Promotion and
Maintenance
, 4. A nurse is assessing the printout from the fetal monitor. What is the legal
responsibilit y of the nurse?
a. Correctl y identifying abnormal FHR patterns and prescribing
medication
b. Correctl y identifying abnormal FHR patterns and noti fying the
health care provider
c. The nurse is not legall y responsible for fetal monitoring
d. Providing technical assessment to the monitor technicians
ANS: B
Nurses are responsible for the timel y notification of the primary
caregiver in the event of an abnor mal fetal heart rate (FHR) pattern.
The nurse cannot write a medication order.
DIF: Cognitive Level: Application REF: p. 817 OBJ: 10
TOP: Fetal monitoring KEY: Nursing Process Step:
Assessment MSC: NC LEX: Health Promotion and Maintenance
5. A mother is in earl y labor and asks the nurse how long the labor will last.
The nurse explains that the first stage of labor lasts from the beginning of
regular contractions until when?
a. The cervix is completel y effaced.
b. The baby is in position.
c. The cervix is full y dilated.
d. The woman begins pushing.
ANS: C
