Chapter 20 Intrapartum Nursing Assessment
1) The nurse is admitting a client to the birthing unit. What question should
the nurse ask to gain a better understanding of the clients psychosocial status?
1. How did you decide to have your baby at this hospital?
2. Who will be your labor support person?
3. Have you chosen names for your baby yet?
4. What feeding method will you use for your baby?
Answer: 2
Explanation: 2. The expectant mothers partner or support person is an important
member of the birthing team, and assessments of the couples coping,
interactions, and teamwork are integral to the nurses knowledge base. The
nurses physical presence with the laboring woman provides the best opportunity
for ongoing assessment.
Page Ref: 469
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences,
and expressed needs as part of clinical interview, implementation of care
plan, and evaluation of care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Context and Environment: Read and
interpret data; apply health promotion/disease prevention strategies; apply
health policy; conduct population-based transcultural health assessments and
interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and
cultural assessments necessary for optimum maternal-fetal outcome.
MNL LO: 3.1.4 Examine the nursing assessments associated with each
stage/phase of labor.
1
Copyright 2016 Pearson Education, Inc.
,2) The nurse is admitting a client to the labor and delivery unit. Which aspect
of the clients history requires notifying the physician?
1. Blood pressure 120/88
,2. Father a carrier of sickle-cell trait
3. Dark red vaginal bleeding
4. History of domestic abuse
Answer: 3
Explanation: 3. Third-trimester bleeding is caused by either placenta previa
or abruptio placentae. Dark red bleeding usually indicates abruptio placentae,
which is life-threatening to both mother and fetus.
Page Ref: 473
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: V. B. 4. Communicate observations or
concerns related to hazards and errors to patients, families, and the health
care team. | AACN Essentials Competencies: IX. 12. Create a safe environment
that results in high quality patient outcomes. | NLN Competencies: Quality and
Safety: Communicate effectively with different individuals (team members,
other care providers, patients, families, etc.) so as to minimize risks associated
with handoffs among providers and across transitions in care. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and
cultural assessments necessary for optimum maternal-fetal outcome.
MNL LO: 3.1.4 Examine the nursing assessments associated with each
stage/phase of labor.
3) The nurse is working with a pregnant adolescent. The client asks the nurse
how the babys condition is determined during labor. The nurses best response
is that during labor, the nurse will do which of the following?
1. Check the clients cervix by doing a pelvic exam every 2 hours.
2. Assess the fetuss heart rate with an electronic fetal monitor.
3. Look at the color and amount of bloody show that the client has.
4. Verify that the clients contractions are strong but not too close together.
Answer: 2
, Explanation: 2. This statement best answers the question the client has asked.
Page Ref: 480
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and
self-care management. | AACN Essentials Competencies: IX. 7. Provide
appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-
Centered Care: Communicate information effectively; listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and
cultural assessments necessary for optimum maternal-fetal outcome.
MNL LO: 3.1.4 Examine the nursing assessments associated with each
stage/phase of labor.
2
Copyright 2016 Pearson Education, Inc.
4) During the initial intrapartal assessment of a client in early labor, the nurse
performs a vaginal examination. The clients partner asks why this pelvic
exam needs to be done. The nurse should explain that the purpose of the vaginal
exam is to obtain information about which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Uterine contraction pattern
2. Fetal position
3. Presence of the mucous plug
4. Cervical dilation and effacement
5. Presenting part
Answer: 4, 5
1) The nurse is admitting a client to the birthing unit. What question should
the nurse ask to gain a better understanding of the clients psychosocial status?
1. How did you decide to have your baby at this hospital?
2. Who will be your labor support person?
3. Have you chosen names for your baby yet?
4. What feeding method will you use for your baby?
Answer: 2
Explanation: 2. The expectant mothers partner or support person is an important
member of the birthing team, and assessments of the couples coping,
interactions, and teamwork are integral to the nurses knowledge base. The
nurses physical presence with the laboring woman provides the best opportunity
for ongoing assessment.
Page Ref: 469
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences,
and expressed needs as part of clinical interview, implementation of care
plan, and evaluation of care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Context and Environment: Read and
interpret data; apply health promotion/disease prevention strategies; apply
health policy; conduct population-based transcultural health assessments and
interventions. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and
cultural assessments necessary for optimum maternal-fetal outcome.
MNL LO: 3.1.4 Examine the nursing assessments associated with each
stage/phase of labor.
1
Copyright 2016 Pearson Education, Inc.
,2) The nurse is admitting a client to the labor and delivery unit. Which aspect
of the clients history requires notifying the physician?
1. Blood pressure 120/88
,2. Father a carrier of sickle-cell trait
3. Dark red vaginal bleeding
4. History of domestic abuse
Answer: 3
Explanation: 3. Third-trimester bleeding is caused by either placenta previa
or abruptio placentae. Dark red bleeding usually indicates abruptio placentae,
which is life-threatening to both mother and fetus.
Page Ref: 473
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: V. B. 4. Communicate observations or
concerns related to hazards and errors to patients, families, and the health
care team. | AACN Essentials Competencies: IX. 12. Create a safe environment
that results in high quality patient outcomes. | NLN Competencies: Quality and
Safety: Communicate effectively with different individuals (team members,
other care providers, patients, families, etc.) so as to minimize risks associated
with handoffs among providers and across transitions in care. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and
cultural assessments necessary for optimum maternal-fetal outcome.
MNL LO: 3.1.4 Examine the nursing assessments associated with each
stage/phase of labor.
3) The nurse is working with a pregnant adolescent. The client asks the nurse
how the babys condition is determined during labor. The nurses best response
is that during labor, the nurse will do which of the following?
1. Check the clients cervix by doing a pelvic exam every 2 hours.
2. Assess the fetuss heart rate with an electronic fetal monitor.
3. Look at the color and amount of bloody show that the client has.
4. Verify that the clients contractions are strong but not too close together.
Answer: 2
, Explanation: 2. This statement best answers the question the client has asked.
Page Ref: 480
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and
self-care management. | AACN Essentials Competencies: IX. 7. Provide
appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-
Centered Care: Communicate information effectively; listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and
cultural assessments necessary for optimum maternal-fetal outcome.
MNL LO: 3.1.4 Examine the nursing assessments associated with each
stage/phase of labor.
2
Copyright 2016 Pearson Education, Inc.
4) During the initial intrapartal assessment of a client in early labor, the nurse
performs a vaginal examination. The clients partner asks why this pelvic
exam needs to be done. The nurse should explain that the purpose of the vaginal
exam is to obtain information about which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Uterine contraction pattern
2. Fetal position
3. Presence of the mucous plug
4. Cervical dilation and effacement
5. Presenting part
Answer: 4, 5
