Maternity Nursing Care During Labor
& Delivery EAQ QUESTIONS AND
ANSWERS
Which information is important to obtain when assessing a patient admitted with ruptured
membranes? - correct answer ✔✔ Odor of fluid
Amount of fluid
Time of rupture
Color of amniotic fluid
Which test is performed to determine if membranes are ruptured? - correct answer ✔✔ Fern
test
In many instances, a sterile speculum examination and a nitrazine (pH) and fern test are
performed to confirm that fluid seepage is indeed amniotic fluid.
Which characteristic is associated with false labor contractions? - correct answer ✔✔ Decrease
in intensity with ambulation
After reviewing the laboratory reports of a pregnant patient at term, the primary health care
provider (PHP) advises the nurse to administer intravenous (IV) fluids to the patient. Which is
the reason for this? - correct answer ✔✔ Dehydration
After a pelvic examination of a pregnant woman, the nurse concludes that the patient may
require a forceps-assisted delivery. What pelvic finding would support this conclusion? - correct
answer ✔✔ Subpubic arch is narrow
,The presence of a narrow subpubic arch indicates that the patient has either an android pelvis
or an anthropoid pelvis. In such situations, the fetus may not easily pass through the birth canal
and the patient may require a forceps-assisted delivery. The presence of a slightly ovoid pelvis
with moderate depth and blunt ischial spines indicates a gynecoid pelvis. Women with gynecoid
(ovoid-shaped) pelvises have wider subpubic arches, which allow the fetus to more easily pass
through the birth canal.
A patient sustained a first-degree laceration during childbirth. Which physical finding should the
nurse infer from this? - correct answer ✔✔ The laceration extends through the skin and
structures superficial to muscles.
A first-degree laceration extends through the skin and structures superficial to muscles. A
second-degree laceration extends through muscles of the perineal body. A third-degree
laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the
anterior rectal wall.
Which is the most significant finding in a urinalysis for a patient with preeclampsia? - correct
answer ✔✔ Protein
Protein is a significant finding in a urinalysis for a patient diagnosed with preeclampsia.
Normally protein should not be present in the urine. It is reflective of glomerular damage
caused by hypertension in preeclampsia.
When managing the care of a patient in the second stage of labor, the nurse uses various
measures to enhance the progress of fetal descent. Which measure does the nurse include? -
correct answer ✔✔ Encouraging the woman to try various upright positions, including squatting
and standing
Under which circumstance should a vaginal examination be performed by the nurse? - correct
answer ✔✔ An admission to the hospital at the start of labor
On maternal perception of perineal pressure or the urge to bear down
When membranes rupture
, Vaginal examinations should be performed when the woman is admitted to the hospital or
birthing center at the start of labor. When the woman perceives perineal pressure or the urge to
bear down is an appropriate time to perform a vaginal examination. After rupture of
membranes (ROM), a vaginal examination should be performed. The nurse must be aware that
there is an increased risk of prolapsed cord immediately after ROM.
Concerning the third stage of labor, of which statement should the nurses be aware? - correct
answer ✔✔ The duration of the third stage may be as short as 3 to 5 minutes.
The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within
normal limits. The third stage of labor lasts from birth of the fetus until the placenta is
delivered.
Which patient is more susceptible to soft-tissue damage with vaginal deliveries? - correct
answer ✔✔ Nulliparous patient
Patient needing forceps delivery
Patient with fetal breech presentation
A nulliparous patient has rigid perineal tissue, making it susceptible to injury. Fetal breech
presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps
delivery also increases the risk of injury due to undue stretch of the perineum.
Which nursing intervention will help explain the procedure of a vaginal examination to a non-
English speaking pregnant patient? - correct answer ✔✔ Call a service for an interpreter.
After reviewing the urinalysis reports of a pregnant patient, the nurse finds that the patient has
preeclampsia. Which did the nurse find in the patient's urinalysis report? - correct answer ✔✔
Proteins
& Delivery EAQ QUESTIONS AND
ANSWERS
Which information is important to obtain when assessing a patient admitted with ruptured
membranes? - correct answer ✔✔ Odor of fluid
Amount of fluid
Time of rupture
Color of amniotic fluid
Which test is performed to determine if membranes are ruptured? - correct answer ✔✔ Fern
test
In many instances, a sterile speculum examination and a nitrazine (pH) and fern test are
performed to confirm that fluid seepage is indeed amniotic fluid.
Which characteristic is associated with false labor contractions? - correct answer ✔✔ Decrease
in intensity with ambulation
After reviewing the laboratory reports of a pregnant patient at term, the primary health care
provider (PHP) advises the nurse to administer intravenous (IV) fluids to the patient. Which is
the reason for this? - correct answer ✔✔ Dehydration
After a pelvic examination of a pregnant woman, the nurse concludes that the patient may
require a forceps-assisted delivery. What pelvic finding would support this conclusion? - correct
answer ✔✔ Subpubic arch is narrow
,The presence of a narrow subpubic arch indicates that the patient has either an android pelvis
or an anthropoid pelvis. In such situations, the fetus may not easily pass through the birth canal
and the patient may require a forceps-assisted delivery. The presence of a slightly ovoid pelvis
with moderate depth and blunt ischial spines indicates a gynecoid pelvis. Women with gynecoid
(ovoid-shaped) pelvises have wider subpubic arches, which allow the fetus to more easily pass
through the birth canal.
A patient sustained a first-degree laceration during childbirth. Which physical finding should the
nurse infer from this? - correct answer ✔✔ The laceration extends through the skin and
structures superficial to muscles.
A first-degree laceration extends through the skin and structures superficial to muscles. A
second-degree laceration extends through muscles of the perineal body. A third-degree
laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the
anterior rectal wall.
Which is the most significant finding in a urinalysis for a patient with preeclampsia? - correct
answer ✔✔ Protein
Protein is a significant finding in a urinalysis for a patient diagnosed with preeclampsia.
Normally protein should not be present in the urine. It is reflective of glomerular damage
caused by hypertension in preeclampsia.
When managing the care of a patient in the second stage of labor, the nurse uses various
measures to enhance the progress of fetal descent. Which measure does the nurse include? -
correct answer ✔✔ Encouraging the woman to try various upright positions, including squatting
and standing
Under which circumstance should a vaginal examination be performed by the nurse? - correct
answer ✔✔ An admission to the hospital at the start of labor
On maternal perception of perineal pressure or the urge to bear down
When membranes rupture
, Vaginal examinations should be performed when the woman is admitted to the hospital or
birthing center at the start of labor. When the woman perceives perineal pressure or the urge to
bear down is an appropriate time to perform a vaginal examination. After rupture of
membranes (ROM), a vaginal examination should be performed. The nurse must be aware that
there is an increased risk of prolapsed cord immediately after ROM.
Concerning the third stage of labor, of which statement should the nurses be aware? - correct
answer ✔✔ The duration of the third stage may be as short as 3 to 5 minutes.
The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within
normal limits. The third stage of labor lasts from birth of the fetus until the placenta is
delivered.
Which patient is more susceptible to soft-tissue damage with vaginal deliveries? - correct
answer ✔✔ Nulliparous patient
Patient needing forceps delivery
Patient with fetal breech presentation
A nulliparous patient has rigid perineal tissue, making it susceptible to injury. Fetal breech
presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps
delivery also increases the risk of injury due to undue stretch of the perineum.
Which nursing intervention will help explain the procedure of a vaginal examination to a non-
English speaking pregnant patient? - correct answer ✔✔ Call a service for an interpreter.
After reviewing the urinalysis reports of a pregnant patient, the nurse finds that the patient has
preeclampsia. Which did the nurse find in the patient's urinalysis report? - correct answer ✔✔
Proteins
