Chapter 19: Nursing Care of the Family During Labor and Birth
MULTIPLE CHOICE
1. Which statement by the client will assist the nurse in determining whether she is in true
labor as opposed to false labor?
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.”
ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is
experiencing true labor. The 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 (ROM) 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.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. When a nulliparous woman telephones the hospital to report that she is in labor, what
intervention should the nurN
seUpR orI
riS zeG?TB.COM
itiN
a. Instructing the woman to stay home until her membranes rupture.
b. Emphasizing that food and fluid intake should stop.
c. Arranging for the woman to come to the hospital for labor evaluation.
d. Asking the woman to describe why she believes she is in labor.
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 her
assessment and gather data. The initial nursing activity should be to gather data about the
woman’s status. The amniotic membranes may or may not spontaneously rupture during
labor. The client may be instructed to stay home until the uterine contractions become
strong and regular. Before instructing the woman to come to the hospital, the nurse should
initiate her assessment during the telephone interview. After this assessment has been made,
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 client or her primary health care
provider.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours
earlier. This client is at increased risk for which complication?
, a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension
ANS: A
When the membranes rupture (ROM), microorganisms from the vagina can ascend into the
amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or
maternal bleeding. Although ROM may increase the intensity of the contractions and
facilitate active labor, it does not result in precipitous labor. ROM has no correlation with
supine hypotension.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning | Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
4. The uterine contractions of a woman early in the active phase of labor are assessed by an
internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4
minutes and last an average of 55 to 60 seconds. They are becoming more regular and are
moderate to strong. Based on this information, what would a prudent nurse do next?
a. Immediately notify the woman’s primary health care provider.
b. Prepare to administer an oxytocic to stimulate uterine activity.
c. Document the findings because they reflect the expected contraction pattern for the
active phase of labor.
d. Prepare the woman for the onset of the second stage of labor.
ANS: C NURSINGTB.COM
The nurse is responsible for monitoring the uterine contractions to ascertain whether they
are powerful and frequent enough to accomplish the work of expelling the fetus and the
placenta. In addition, the nurse documents these findings in the client’s medical record. This
labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing
indicates a need to notify the primary health care provider at this time. Oxytocin
augmentation is not needed for this labor pattern; this contraction pattern indicates that the
woman is in active labor. Her contractions will eventually become stronger, last longer, and
come closer together during the transition phase of the first stage of labor. The transition
phase precedes the second stage of labor, or delivery of the fetus.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
5. Which action is correct when palpation is used to assess the characteristics and pattern of
uterine contractions?
a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone
with the fingertips
b. Determining the frequency by timing from the end of one contraction to the end of
the next contraction
c. Evaluating the intensity by pressing the fingertips into the uterine fundus
d. Assessing uterine contractions every 30 minutes throughout the first stage of labor
, ANS: C
The nurse or primary health care provider may assess uterine activity by palpating the
fundal section of the uterus using the fingertips. Many women may experience labor pain in
the lower segment of the uterus, which may be unrelated to the firmness of the contraction
detectable in the uterine fundus. The frequency of uterine contractions is determined by
palpating from the beginning of one contraction to the beginning of the next contraction.
Assessment of uterine activity is performed in intervals based on the stage of labor. As labor
progresses, this assessment is performed more frequently.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
6. When assessing a woman in the first stage of labor, which clinical finding will alert the
nurse that uterine contractions are effective?
a. Dilation of the cervix
b. Descent of the fetus to –2 station
c. Rupture of the amniotic membranes (ROM)
d. Increase in bloody show
ANS: A
The vaginal examination reveals whether the woman is in true labor. Cervical change,
especially dilation, in the presence of adequate labor, indicates that the woman is in true
labor. Engagement and descent of the fetus are not synonymous and may occur before labor.
ROM may occur with or without the presence of labor. Bloody show may indicate a slow,
progressive cervical change (e.g., effacement) in both true and false labor.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment | Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse performs a vaginal examination to assess a client’s labor progress. Which action
should the nurse take next?
a. Perform an examination at least once every hour during the active phase of labor.
b. Perform the examination with the woman in the supine position.
c. Wear two clean gloves for each examination.
d. Discuss the findings with the woman and her partner.
ANS: D
The nurse should discuss the findings of the vaginal examination with the woman and her
partner, as well as report the findings to the primary care provider. A vaginal examination
should be performed only when indicated by the status of the woman and her fetus. The
woman should be positioned so as to avoid supine hypotension. The examiner should wear a
sterile glove while performing a vaginal examination for a laboring woman.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
8. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured.
What is the nurse’s highest priority in this situation?
MULTIPLE CHOICE
1. Which statement by the client will assist the nurse in determining whether she is in true
labor as opposed to false labor?
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.”
ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is
experiencing true labor. The 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 (ROM) 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.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. When a nulliparous woman telephones the hospital to report that she is in labor, what
intervention should the nurN
seUpR orI
riS zeG?TB.COM
itiN
a. Instructing the woman to stay home until her membranes rupture.
b. Emphasizing that food and fluid intake should stop.
c. Arranging for the woman to come to the hospital for labor evaluation.
d. Asking the woman to describe why she believes she is in labor.
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 her
assessment and gather data. The initial nursing activity should be to gather data about the
woman’s status. The amniotic membranes may or may not spontaneously rupture during
labor. The client may be instructed to stay home until the uterine contractions become
strong and regular. Before instructing the woman to come to the hospital, the nurse should
initiate her assessment during the telephone interview. After this assessment has been made,
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 client or her primary health care
provider.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours
earlier. This client is at increased risk for which complication?
, a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension
ANS: A
When the membranes rupture (ROM), microorganisms from the vagina can ascend into the
amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or
maternal bleeding. Although ROM may increase the intensity of the contractions and
facilitate active labor, it does not result in precipitous labor. ROM has no correlation with
supine hypotension.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning | Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
4. The uterine contractions of a woman early in the active phase of labor are assessed by an
internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4
minutes and last an average of 55 to 60 seconds. They are becoming more regular and are
moderate to strong. Based on this information, what would a prudent nurse do next?
a. Immediately notify the woman’s primary health care provider.
b. Prepare to administer an oxytocic to stimulate uterine activity.
c. Document the findings because they reflect the expected contraction pattern for the
active phase of labor.
d. Prepare the woman for the onset of the second stage of labor.
ANS: C NURSINGTB.COM
The nurse is responsible for monitoring the uterine contractions to ascertain whether they
are powerful and frequent enough to accomplish the work of expelling the fetus and the
placenta. In addition, the nurse documents these findings in the client’s medical record. This
labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing
indicates a need to notify the primary health care provider at this time. Oxytocin
augmentation is not needed for this labor pattern; this contraction pattern indicates that the
woman is in active labor. Her contractions will eventually become stronger, last longer, and
come closer together during the transition phase of the first stage of labor. The transition
phase precedes the second stage of labor, or delivery of the fetus.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
5. Which action is correct when palpation is used to assess the characteristics and pattern of
uterine contractions?
a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone
with the fingertips
b. Determining the frequency by timing from the end of one contraction to the end of
the next contraction
c. Evaluating the intensity by pressing the fingertips into the uterine fundus
d. Assessing uterine contractions every 30 minutes throughout the first stage of labor
, ANS: C
The nurse or primary health care provider may assess uterine activity by palpating the
fundal section of the uterus using the fingertips. Many women may experience labor pain in
the lower segment of the uterus, which may be unrelated to the firmness of the contraction
detectable in the uterine fundus. The frequency of uterine contractions is determined by
palpating from the beginning of one contraction to the beginning of the next contraction.
Assessment of uterine activity is performed in intervals based on the stage of labor. As labor
progresses, this assessment is performed more frequently.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
6. When assessing a woman in the first stage of labor, which clinical finding will alert the
nurse that uterine contractions are effective?
a. Dilation of the cervix
b. Descent of the fetus to –2 station
c. Rupture of the amniotic membranes (ROM)
d. Increase in bloody show
ANS: A
The vaginal examination reveals whether the woman is in true labor. Cervical change,
especially dilation, in the presence of adequate labor, indicates that the woman is in true
labor. Engagement and descent of the fetus are not synonymous and may occur before labor.
ROM may occur with or without the presence of labor. Bloody show may indicate a slow,
progressive cervical change (e.g., effacement) in both true and false labor.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment | Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse performs a vaginal examination to assess a client’s labor progress. Which action
should the nurse take next?
a. Perform an examination at least once every hour during the active phase of labor.
b. Perform the examination with the woman in the supine position.
c. Wear two clean gloves for each examination.
d. Discuss the findings with the woman and her partner.
ANS: D
The nurse should discuss the findings of the vaginal examination with the woman and her
partner, as well as report the findings to the primary care provider. A vaginal examination
should be performed only when indicated by the status of the woman and her fetus. The
woman should be positioned so as to avoid supine hypotension. The examiner should wear a
sterile glove while performing a vaginal examination for a laboring woman.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
8. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured.
What is the nurse’s highest priority in this situation?
