C HAPTER 06: N URSING C ARE OF M OTHER AND
I NFANT D URING L ABOR AND B IRTH
Introduction to Maternity and Pediatric Nursing , 8th Edition ; Leifer
MULTIPLE CHOICE
1. The nurse observes on the fetal monitor a pattern of a 15 -beat increase in
the fetal heart rate that lasts 15 to 20 seconds. What does this pattern
indicate?
a. A well-ox ygenated fetus
b. Compression of the umbilical cord
c. Compression of the fetal head
d. Uteroplacental insufficiency
ANS: A
Accelerations in the fetal heart rate suggest that the fetus is well
oxygenated.
DIF: Cognitive Level: Anal ysis REF: Page 141 TOP:
Fetal Accelerations KEY: Nursing Process Step: Data
Collection MSC: NC LEX: Physiological Integrit y:
Physiological Adaptation
2. What is the most appropriate statement from the nurse when coaching the
laboring woman with a full y dilated cervix to push?
, a. At the beginning of a contraction, hold your breath and push for 10
seconds.
b. Take a deep breath and push between contractions.
c. Begin pushing when a contraction starts and continue for the
duration of the contraction .
d. At the beginning of a contraction, take two deep breaths and push
with the second exhalation.
ANS: D
When the cervix is full y dilated , the woman should take a deep breath
and exhale at the beginning of a contraction, and then take another
deep breath and push while exhaling.
DIF: Cognitive Level: Application REF: Page 148 TOP:
Instructions for Pushing KEY: Nursing Process Step:
Implementation MSC: NC LEX: Physiological Integrit y:
Physiological Adaptation
3. What is the most important nursing intervention during the fourth stage of
labor?
a. Monitor the frequency and intensit y of contractions.
b. Provide comfort measures.
c. Assess for hemorrha ge.
d. Promote bonding.
ANS: C
Immediatel y after giving birth, every woman is assessed for signs of
hemorrhage.
, DIF: Cognitive Level: Comprehension REF: Page 153
TOP: Postdelivery Hemorrhage KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Reduction of Risk
4. One hour postdelivery the nurse notes the new mother has saturated three
perineal pads. What is the most appropriate nursing action?
a. Check the fundus for position and firmness.
b. Report to the doctor immediatel y.
c. Change the pads and chart the time.
d. Time how long it takes to soak one pad.
ANS: A
Increased lochia may indicate hemorrhage. the fundus should be
assessed for firmness. One pad an hour is an acceptable rate for
immediate postdelivery.
DIF: Cognitive Level: App lication REF: Page 153 TOP:
Nursing Postdelivery Hemorrhage KEY: Nursing Process
Step: Implementation MSC: NC LEX: Physiological
Integrit y: Reduction of Risk
5. While caring for a laboring woman, the nurse notices a pattern of variable
decelerations in fetal heart rate with uterine contractions. What is the
nurses initial action?
a. Stop the ox ytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
I NFANT D URING L ABOR AND B IRTH
Introduction to Maternity and Pediatric Nursing , 8th Edition ; Leifer
MULTIPLE CHOICE
1. The nurse observes on the fetal monitor a pattern of a 15 -beat increase in
the fetal heart rate that lasts 15 to 20 seconds. What does this pattern
indicate?
a. A well-ox ygenated fetus
b. Compression of the umbilical cord
c. Compression of the fetal head
d. Uteroplacental insufficiency
ANS: A
Accelerations in the fetal heart rate suggest that the fetus is well
oxygenated.
DIF: Cognitive Level: Anal ysis REF: Page 141 TOP:
Fetal Accelerations KEY: Nursing Process Step: Data
Collection MSC: NC LEX: Physiological Integrit y:
Physiological Adaptation
2. What is the most appropriate statement from the nurse when coaching the
laboring woman with a full y dilated cervix to push?
, a. At the beginning of a contraction, hold your breath and push for 10
seconds.
b. Take a deep breath and push between contractions.
c. Begin pushing when a contraction starts and continue for the
duration of the contraction .
d. At the beginning of a contraction, take two deep breaths and push
with the second exhalation.
ANS: D
When the cervix is full y dilated , the woman should take a deep breath
and exhale at the beginning of a contraction, and then take another
deep breath and push while exhaling.
DIF: Cognitive Level: Application REF: Page 148 TOP:
Instructions for Pushing KEY: Nursing Process Step:
Implementation MSC: NC LEX: Physiological Integrit y:
Physiological Adaptation
3. What is the most important nursing intervention during the fourth stage of
labor?
a. Monitor the frequency and intensit y of contractions.
b. Provide comfort measures.
c. Assess for hemorrha ge.
d. Promote bonding.
ANS: C
Immediatel y after giving birth, every woman is assessed for signs of
hemorrhage.
, DIF: Cognitive Level: Comprehension REF: Page 153
TOP: Postdelivery Hemorrhage KEY: Nursing
Process Step: Implementation MSC: NC LEX:
Physiological Integrity: Reduction of Risk
4. One hour postdelivery the nurse notes the new mother has saturated three
perineal pads. What is the most appropriate nursing action?
a. Check the fundus for position and firmness.
b. Report to the doctor immediatel y.
c. Change the pads and chart the time.
d. Time how long it takes to soak one pad.
ANS: A
Increased lochia may indicate hemorrhage. the fundus should be
assessed for firmness. One pad an hour is an acceptable rate for
immediate postdelivery.
DIF: Cognitive Level: App lication REF: Page 153 TOP:
Nursing Postdelivery Hemorrhage KEY: Nursing Process
Step: Implementation MSC: NC LEX: Physiological
Integrit y: Reduction of Risk
5. While caring for a laboring woman, the nurse notices a pattern of variable
decelerations in fetal heart rate with uterine contractions. What is the
nurses initial action?
a. Stop the ox ytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
