Maternal-Newborn chapter 15
Which comfort measure should the nurse utilize 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 client's face and neck
D: keep the room lights lit so the client and her coach can see everything -
(correct Answer) - A: recommend frequent position changes
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.
Which assessment finding is an indication of hemorrhage in the recently delivered
postpartum patient?
A: elevated pulse rate
B: elevated blood pressure
C: firm funds at the midline
D: saturation of two perineal pads in 4 hours - (correct Answer) - A: elevated
pulse rate
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.
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 -
(correct Answer) - A: helping the woman manage the pain
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.
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 - (correct Answer) - C: a trickle of fluid
from the vagina
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring
evaluation for infection or cord compression. Decreased or the lack of fetal
movement requires further 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.
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 - (correct Answer) -
D: gravida 3, para 2, whose longest previous labor was 4 hours
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.
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 5-9 minutes apart, 20-
30 seconds in duration, and of mild intensity. Cervical dilation is 1-2 cm and
uneffaced (unchanged from admission). Membranes are intact. The nurse should expect
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 - (correct Answer) - D:
discharged home to await the onset of true labor
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.
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which
nursing interventions 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 - (correct Answer) - A: inform the mother that the fetal heart rate is normal
The FHR is within the normal range, so no other action is indicated at this time.
The FHR is within the expected range; reassessment should occur, but not in 5
minutes. The FHR is within the expected range; no further action is necessary at
this point. The gender of the baby cannot be determined by the FHR.
Which clinical finding would be an indication to the nurse that the fetus may be
compromised?
A: active fetal movements
B: fetal heart rate in the 140s
C: contractions lasting 90 seconds
D: meconium-stained amniotic fluid - (correct Answer) - D: meconium-stained
amniotic fluid
When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage
of meconium into the amniotic fluid. Active fetal movement is an expected
occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to
tolerate contractions lasting 90 seconds if the resting phase is sufficient to
Which comfort measure should the nurse utilize 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 client's face and neck
D: keep the room lights lit so the client and her coach can see everything -
(correct Answer) - A: recommend frequent position changes
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.
Which assessment finding is an indication of hemorrhage in the recently delivered
postpartum patient?
A: elevated pulse rate
B: elevated blood pressure
C: firm funds at the midline
D: saturation of two perineal pads in 4 hours - (correct Answer) - A: elevated
pulse rate
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.
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 -
(correct Answer) - A: helping the woman manage the pain
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.
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 - (correct Answer) - C: a trickle of fluid
from the vagina
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring
evaluation for infection or cord compression. Decreased or the lack of fetal
movement requires further 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.
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 - (correct Answer) -
D: gravida 3, para 2, whose longest previous labor was 4 hours
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.
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 5-9 minutes apart, 20-
30 seconds in duration, and of mild intensity. Cervical dilation is 1-2 cm and
uneffaced (unchanged from admission). Membranes are intact. The nurse should expect
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 - (correct Answer) - D:
discharged home to await the onset of true labor
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.
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which
nursing interventions 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 - (correct Answer) - A: inform the mother that the fetal heart rate is normal
The FHR is within the normal range, so no other action is indicated at this time.
The FHR is within the expected range; reassessment should occur, but not in 5
minutes. The FHR is within the expected range; no further action is necessary at
this point. The gender of the baby cannot be determined by the FHR.
Which clinical finding would be an indication to the nurse that the fetus may be
compromised?
A: active fetal movements
B: fetal heart rate in the 140s
C: contractions lasting 90 seconds
D: meconium-stained amniotic fluid - (correct Answer) - D: meconium-stained
amniotic fluid
When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage
of meconium into the amniotic fluid. Active fetal movement is an expected
occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to
tolerate contractions lasting 90 seconds if the resting phase is sufficient to
