Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition
MULTIPLE CHOICE
1. A nurse observes the patient bearing down with contractions and crying out, “The baby is
coming!” What is the best nursing intervention?
a. Find the primary health care provider.
b. Stay with the woman and use the call bell to get help.
c. Send the woman’s partner to locate a registered nurse.
d. Assist with deep breathing to slow the labour process.
ANS: B
If birth appears to be imminent, the nurse should not leave the woman and should
summon help with the call bell.
DIF: Cognitive Level: Application REF: 153 OBJ: 8
TOP: Imminent Birth KEY: Nursing Process Step: Implementation
2. A 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-oxygenated 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: Analysis REF: 148 OBJ: 8
TOP: Fetal Accelerations KEY: Nursing Process Step: Data
Collection
,3. What is the most appropriate statement from a nurse when coaching the labouring woman
with a fully 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 a deep breath and keep your glottis open
while pushing.”
ANS: D
When the cervix is fully dilated, the woman should take a deep breath and then push
while exhaling.
DIF: Cognitive Level: Application REF: 158 OBJ: 8
TOP: Second Stage of Labour KEY: Nursing Process Step:
Implementation
4. What is the most important nursing intervention during the fourth stage of labour?
a. Monitor the frequency and intensity of contractions.
b. Provide comfort measures.
c. Assess for hemorrhage.
d. Promote bonding.
ANS: C
Immediately after giving birth, every woman is assessed for signs of hemorrhage.
DIF: Cognitive Level: Comprehension REF: 160 OBJ: 8
TOP: Fourth Stage of Labour KEY: Nursing Process Step:
Implementation
5. One hour after a birth a nurse notes a 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 health care provider immediately.
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 per hour is an acceptable rate for immediate post birth blood loss.
DIF: Cognitive Level: Application REF: 161 OBJ: 8
TOP: Postpartum Hemorrhage KEY: Nursing Process Step:
Implementation
6. While caring for a labouring woman, a nurse notices a pattern of variable decelerations in
fetal heart rate with uterine contractions. What is the nurse’s initial action?
a. Stop the oxytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
d. Start oxygen via nasal cannula.
ANS: C
Repositioning the woman is the first response to a pattern of variable decelerations. If
the decelerations continue, then oxygen should be administered and/or the flow rate of
oxygen should be increased.
DIF: Cognitive Level: Application REF: 150 OBJ: 8
TOP: Decelerations KEY: Nursing Process Step: Implementation
7. How should a nurse intervene to relieve perineal bruising and edema following birth?
a. Use ice packs intermittently on the area for 24 hours.
b. Place a warm pack on the perineal area for 24 hours.
c. Administer Aspirin to relieve inflammation.
d. Change the perineal pad frequently.
ANS: A
An ice pack can be placed on the mother’s perineum to reduce bruising and edema for
24 hours followed by warm packs after 24 hours after birth.
DIF: Cognitive Level: Application REF: 161 OBJ: 8
TOP: Postpartum Comfort KEY: Nursing Process Step: Implementation
MULTIPLE CHOICE
1. A nurse observes the patient bearing down with contractions and crying out, “The baby is
coming!” What is the best nursing intervention?
a. Find the primary health care provider.
b. Stay with the woman and use the call bell to get help.
c. Send the woman’s partner to locate a registered nurse.
d. Assist with deep breathing to slow the labour process.
ANS: B
If birth appears to be imminent, the nurse should not leave the woman and should
summon help with the call bell.
DIF: Cognitive Level: Application REF: 153 OBJ: 8
TOP: Imminent Birth KEY: Nursing Process Step: Implementation
2. A 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-oxygenated 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: Analysis REF: 148 OBJ: 8
TOP: Fetal Accelerations KEY: Nursing Process Step: Data
Collection
,3. What is the most appropriate statement from a nurse when coaching the labouring woman
with a fully 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 a deep breath and keep your glottis open
while pushing.”
ANS: D
When the cervix is fully dilated, the woman should take a deep breath and then push
while exhaling.
DIF: Cognitive Level: Application REF: 158 OBJ: 8
TOP: Second Stage of Labour KEY: Nursing Process Step:
Implementation
4. What is the most important nursing intervention during the fourth stage of labour?
a. Monitor the frequency and intensity of contractions.
b. Provide comfort measures.
c. Assess for hemorrhage.
d. Promote bonding.
ANS: C
Immediately after giving birth, every woman is assessed for signs of hemorrhage.
DIF: Cognitive Level: Comprehension REF: 160 OBJ: 8
TOP: Fourth Stage of Labour KEY: Nursing Process Step:
Implementation
5. One hour after a birth a nurse notes a 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 health care provider immediately.
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 per hour is an acceptable rate for immediate post birth blood loss.
DIF: Cognitive Level: Application REF: 161 OBJ: 8
TOP: Postpartum Hemorrhage KEY: Nursing Process Step:
Implementation
6. While caring for a labouring woman, a nurse notices a pattern of variable decelerations in
fetal heart rate with uterine contractions. What is the nurse’s initial action?
a. Stop the oxytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
d. Start oxygen via nasal cannula.
ANS: C
Repositioning the woman is the first response to a pattern of variable decelerations. If
the decelerations continue, then oxygen should be administered and/or the flow rate of
oxygen should be increased.
DIF: Cognitive Level: Application REF: 150 OBJ: 8
TOP: Decelerations KEY: Nursing Process Step: Implementation
7. How should a nurse intervene to relieve perineal bruising and edema following birth?
a. Use ice packs intermittently on the area for 24 hours.
b. Place a warm pack on the perineal area for 24 hours.
c. Administer Aspirin to relieve inflammation.
d. Change the perineal pad frequently.
ANS: A
An ice pack can be placed on the mother’s perineum to reduce bruising and edema for
24 hours followed by warm packs after 24 hours after birth.
DIF: Cognitive Level: Application REF: 161 OBJ: 8
TOP: Postpartum Comfort KEY: Nursing Process Step: Implementation
