Chapter 21 The Family in Childbirth: Needs and Care
1) The laboring client is at 7 cm, with the vertex at a +1 station. Her birth
plan indicates that she and her partner took Lamaze prenatal classes, and they
have planned on a natural, unmedicated birth. Her contractions are every 3
minutes and last 60 seconds. She has used relaxation and breathing
techniques very successfully in her labor until the last 15 minutes. Now, during
contractions, she is writhing on the bed and screaming. Her labor partner is
rubbing the clients back and speaking to her quietly. Which nursing diagnosis
should the nurse incorporate into the plan of care for this client?
1. Fear/Anxiety related to discomfort of labor and unknown labor outcome
2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal
descent
3. Coping: Family, Compromised, related to labor process
4. Knowledge, Deficient, related to lack of information about normal labor
process and comfort measures
Answer: 2
Explanation: 2. The client is exhibiting signs of acute pain, which is both
common and expected in the transitional phase of labor.
Page Ref: 509
Cognitive Level: Applying Client Need/Sub: Health Promotion and
Maintenance: Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to
relieve pain and suffering in light of patient values, preferences, and
expressed needs. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient
and family preferences. | NLN Competencies: Relationship-Centered Care:
Promote and accept the patients emotions; accept and respond to distress in
patient and self; facilitate hope, trust, and faith. | Nursing/Integrated
Concepts: Nursing Process: Diagnosis
Learning Outcome: 1 Identify nursing diagnoses specific to the first, second,
third, and fourth stages of labor.
MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family
during the 1st stage of labor.
1
Copyright 2016 Pearson Education, Inc.
,2) A client is admitted to the labor and delivery unit with contractions that are
regular, are 2 minutes apart, and last 60 seconds. She reports that her labor
began about 6 hours ago, and she had bloody show earlier that morning. A
vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8
cm dilated. The client asks what part of labor she is in. The nurse should inform
the client that she is in what phase of labor?
1. Latent phase
2. Active phase
3. Transition phase
4. Fourth stage
Answer: 3
Explanation: 3. The transition phase begins with 8 cm of dilatation, and is
characterized by contractions that are closer and more intense.
Page Ref: 516
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: Assessment
Learning Outcome: 2 Describe factors that are assessed in the laboring
woman during the admission process.
MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family
during the 1st stage of labor.
2
Copyright 2016 Pearson Education, Inc.
3) Usually, the family is advised to arrive at the birth setting at the beginning
of the active phase of labor or when which of the following occur?
Note: Credit will be given only if all correct and no incorrect choices are
selected.
Select all that apply.
1. Rupture of membranes (ROM)
2. Increased fetal movement
3. Decreased fetal movement
4. Any vaginal bleeding
5. Regular, frequent uterine contractions (UCs)
Answer: 1, 3, 4, 5
Explanation: 1. The family is advised to arrive at the birth setting at the
beginning of the active phase of labor or when the membranes rupture.
3. The family is advised to arrive at the birth setting at the beginning of the
active phase of labor or when there is decreased fetal movement.
4. The family is advised to arrive at the birth setting at the beginning of the
active phase of labor or when there is any vaginal bleeding.
, 5. The family is advised to arrive at the birth setting at the beginning of the
active phase of labor or when there are regular, frequent uterine contractions.
Page Ref: 509
Cognitive Level: Understanding
Client Need/Sub: Safe and Effective Care Environment: Management of 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: Assessment
Learning Outcome: 2 Describe factors that are assessed in the laboring
woman during the admission process.
MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family
during the 1st stage of labor.
3
Copyright 2016 Pearson Education, Inc.
4) The client presents to the labor and delivery unit stating that her water broke
2 hours ago. Barring any abnormalities, how often would the nurse expect to
take the clients temperature?
1. Every hour
2. Every 2 hours
3. Every 4 hours
4. Every shift
Answer: 3
Explanation: 3. Maternal temperature is taken every 4 hours unless it is above
37.5C. If elevated, it is taken every hour.
Page Ref: 515
Cognitive Level: Applying
1) The laboring client is at 7 cm, with the vertex at a +1 station. Her birth
plan indicates that she and her partner took Lamaze prenatal classes, and they
have planned on a natural, unmedicated birth. Her contractions are every 3
minutes and last 60 seconds. She has used relaxation and breathing
techniques very successfully in her labor until the last 15 minutes. Now, during
contractions, she is writhing on the bed and screaming. Her labor partner is
rubbing the clients back and speaking to her quietly. Which nursing diagnosis
should the nurse incorporate into the plan of care for this client?
1. Fear/Anxiety related to discomfort of labor and unknown labor outcome
2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal
descent
3. Coping: Family, Compromised, related to labor process
4. Knowledge, Deficient, related to lack of information about normal labor
process and comfort measures
Answer: 2
Explanation: 2. The client is exhibiting signs of acute pain, which is both
common and expected in the transitional phase of labor.
Page Ref: 509
Cognitive Level: Applying Client Need/Sub: Health Promotion and
Maintenance: Ante/Intra/Postpartum and Newborn Care
Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to
relieve pain and suffering in light of patient values, preferences, and
expressed needs. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient
and family preferences. | NLN Competencies: Relationship-Centered Care:
Promote and accept the patients emotions; accept and respond to distress in
patient and self; facilitate hope, trust, and faith. | Nursing/Integrated
Concepts: Nursing Process: Diagnosis
Learning Outcome: 1 Identify nursing diagnoses specific to the first, second,
third, and fourth stages of labor.
MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family
during the 1st stage of labor.
1
Copyright 2016 Pearson Education, Inc.
,2) A client is admitted to the labor and delivery unit with contractions that are
regular, are 2 minutes apart, and last 60 seconds. She reports that her labor
began about 6 hours ago, and she had bloody show earlier that morning. A
vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8
cm dilated. The client asks what part of labor she is in. The nurse should inform
the client that she is in what phase of labor?
1. Latent phase
2. Active phase
3. Transition phase
4. Fourth stage
Answer: 3
Explanation: 3. The transition phase begins with 8 cm of dilatation, and is
characterized by contractions that are closer and more intense.
Page Ref: 516
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: Assessment
Learning Outcome: 2 Describe factors that are assessed in the laboring
woman during the admission process.
MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family
during the 1st stage of labor.
2
Copyright 2016 Pearson Education, Inc.
3) Usually, the family is advised to arrive at the birth setting at the beginning
of the active phase of labor or when which of the following occur?
Note: Credit will be given only if all correct and no incorrect choices are
selected.
Select all that apply.
1. Rupture of membranes (ROM)
2. Increased fetal movement
3. Decreased fetal movement
4. Any vaginal bleeding
5. Regular, frequent uterine contractions (UCs)
Answer: 1, 3, 4, 5
Explanation: 1. The family is advised to arrive at the birth setting at the
beginning of the active phase of labor or when the membranes rupture.
3. The family is advised to arrive at the birth setting at the beginning of the
active phase of labor or when there is decreased fetal movement.
4. The family is advised to arrive at the birth setting at the beginning of the
active phase of labor or when there is any vaginal bleeding.
, 5. The family is advised to arrive at the birth setting at the beginning of the
active phase of labor or when there are regular, frequent uterine contractions.
Page Ref: 509
Cognitive Level: Understanding
Client Need/Sub: Safe and Effective Care Environment: Management of 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: Assessment
Learning Outcome: 2 Describe factors that are assessed in the laboring
woman during the admission process.
MNL LO: 3.2.1 Apply appropriate nursing care for the child-bearing family
during the 1st stage of labor.
3
Copyright 2016 Pearson Education, Inc.
4) The client presents to the labor and delivery unit stating that her water broke
2 hours ago. Barring any abnormalities, how often would the nurse expect to
take the clients temperature?
1. Every hour
2. Every 2 hours
3. Every 4 hours
4. Every shift
Answer: 3
Explanation: 3. Maternal temperature is taken every 4 hours unless it is above
37.5C. If elevated, it is taken every hour.
Page Ref: 515
Cognitive Level: Applying
