Full Test Bank Ch9 Nursing Care During Labor And Childbirth - Safe Maternity Nursing Care 2nd Ed - Exam Resource Pack by Luanne Linnard Palmer. DOCX document preview.
Chapter 9: Nursing Care During Labor and Childbirth
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. When reviewing a laboring patient’s medical record, the nurse sees that a longitudinal lie has been documented. How is the fetus positioned?
1) | The fetus is lying parallel with the mother’s body. |
2) | The fetus is lying perpendicular to the mother’s body. |
3) | The fetus is lying at an angle to the mother’s body between parallel and perpendicular. |
4) | The fetus is in the head-down position. |
____ 2. After reinforcing teaching on how to determine the duration of a contraction, the nurse determines that no further teaching is needed when the mother makes which statement?
1) | “I will time from the end of one contraction to the end of the next contraction.” |
2) | “As soon as the contraction stops, I will time until the next one begins.” |
3) | “I will write down the exact time the contraction begins and ends.” |
4) | “I will time from the beginning of one contraction until the beginning of the next one.” |
____ 3. While the doctor awaits delivery of the placenta after delivery of the newborn, the nurse documents that the patient is in which state of labor?
1) | Latent |
2) | Second |
3) | Transition |
4) | Third |
____ 4. After handing a wrapped newborn to the mother, the nurse sees the umbilical cord lengthening and a sudden trickle of blood at the vaginal opening and recognizes what is about to happen?
1) | Hemorrhage |
2) | Multiple births |
3) | Placental separation |
4) | Uterine inversion |
____ 5. A woman in the latent phase of labor is admitted with a diagnosis of group B streptococcus. Which order should the nurse question?
1) | Begin an infusion of lactated Ringer’s IV at 125 mL/hr. |
2) | Collect her complete blood cell (CBC) count, blood type and screen, and urinalysis. |
3) | Prepare for an amniotomy. |
4) | Administer penicillin G 5 million units IV times one dose, then 2.5 million units every 4 hours. |
____ 6. The nurse reviews the charts of patients who have expressed an interest in home birth and recommends which patient as a potential candidate?
1) | A woman whose 1-year-old child was born via cesarean section |
2) | A primipara with a history of infertility |
3) | A woman desiring an epidural for pain control |
4) | A woman whose last child was stillborn |
____ 7. A laboring patient has received IV fentanyl for labor pain management and requests it again after the cervical check indicates that she is 10 cm dilated and ready to start pushing. Which is the nurse’s best response to the patient’s request?
1) | “Try to give one or two good pushes, and then I’ll get your medication for you.” |
2) | “Receiving medication now is a good idea to help you control the pain of delivery.” |
3) | “Administering a narcotic now could be dangerous because it will suppress the baby’s breathing.” |
4) | “If I give you fentanyl now, you might miss the birth of your baby because you’ll be asleep.” |
____ 8. The physician performs an amniotomy on a laboring woman. Which is the nurse’s priority of care after the procedure?
1) | Pain assessment |
2) | Measuring fetal heart tones |
3) | Assessing cervical dilation |
4) | Encouraging intake of clear liquids |
____ 9. A newborn has a 1-minute Apgar of 3 and a 5-minute Apgar of 5. When will the next Apgar be performed by the nurse?
1) | At 6 minutes of life |
2) | Every 15 minutes until a score of 10 is achieved |
3) | 4 minutes later |
4) | At 10 minutes of life |
____ 10. Which is the nurse’s priority assessment during the immediate post-delivery period?
1) | Inspection of the placenta |
2) | Administration of naloxone |
3) | Assessment of the umbilical cord |
4) | Vaginal bleeding and fundal firmness |
____ 11. The nurse assesses a fetal heart rate as 190 bpm with minimal baseline variability and recurring variable decelerations with moderate variability. How does the nurse classify these findings?
1) | Category I |
2) | Category II |
3) | Category III |
4) | Falling between category II and category III |
____ 12. When planning care, the nurse determines which patient is appropriate for intermittent fetal monitoring?
1) | The woman whose pregnancy is at 38 weeks’ gestation |
2) | The woman receiving an epidural anesthetic |
3) | The woman with controlled gestational diabetes |
4) | The woman whose 5-year-old was born by cesarean section |
____ 13. When obtaining consent to give an infant a vitamin K injection, what information should the nurse give regarding the need for the injection?
1) | “It is a routine procedure for all infants immediately after birth.” |
2) | “It prevents eye infections and preserves eyesight.” |
3) | “Newborns are deficient in vitamin K, which is necessary to help blood clot. We give them vitamin K to help reduce the risk of bleeding.” |
4) | “Immunizations are part of normal newborn care.” |
____ 14. The nurse reviews the medical record of a woman admitted in labor and sees that she has a narrow pelvis. Which of the seven Ps of labor does this impact?
1) | Passage |
2) | Passenger |
3) | Power |
4) | Presentation |
____ 15. When analyzing a fetal-monitor strip, the nurse recognizes which decelerations are not an indication for concern?
1) | Early decelerations |
2) | Late decelerations |
3) | Variable decelerations |
4) | Absent decelerations |
____ 16. The triage nurse receives a call from a pregnant woman. Which statement by the pregnant woman makes the nurse suspect that the woman is experiencing false labor?
1) | “There is bloody discharge in my underwear.” |
2) | “The pain gets more intense when I walk.” |
3) | “The pain is becoming more intense and more frequent.” |
4) | “My belly feels tight off and on but it is not painful.” |
____ 17. The nurse is caring for an obese pregnant woman in preterm labor with intact amniotic membranes who is receiving medications to stop labor. Which type of monitoring is best for this patient?
1) | Internal fetal and contraction monitoring |
2) | Internal fetal and external contraction monitoring |
3) | External fetal and internal contraction monitoring |
4) | External fetal and contraction monitoring |
____ 18. The thinning of the cervix, or effacement, is measured in which of the following?
1) | Stations |
2) | Percentages |
3) | Centimeters |
4) | Inches |
____ 19. Which is an inappropriate nursing intervention for variable decelerations noted on a fetal monitor strip?
1) | Maternal position change |
2) | Amnioinfusion |
3) | IV fluid bolus |
4) | Administer a tocolytic |
____ 20. Apgar scores between _________ indicate that the newborn is adjusting to extrauterine life.
1) | 8 and 11 |
2) | 7 and 10 |
3) | 4 and 6 |
4) | 6 and 10 |
____ 21. The nurse should document a baseline fetal heart rate of 105 as fetal ___________.
1) | Tachycardia |
2) | Normal sinus rhythm |
3) | Sinusoidal rhythm |
4) | Bradycardia |
Completion
____ 22. The nurse is preparing to perform a vaginal cervical examination. Place the steps that the nurse will perform in the proper order from first to last. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Insert the index and middle finger into the vagina.
2) Open the labia and observe for vaginal drainage.
3) Document findings.
4) Perform hand hygiene and provide privacy.
5) Position the woman.
6) Determine effacement, dilation, station, and presenting part.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 23. The seven Ps of labor include which of the following? (Select all that apply.)
1) | Passage |
2) | Perfusion |
3) | Personnel |
4) | Psyche |
5) | Powers |
____ 24. Which is a sign that labor is imminent? (Select all that apply.)
1) | Bloody show |
2) | Fatigue |
3) | Nesting |
4) | Increase in hunger and thirst |
5) | Rupture of membranes |
____ 25. Which maternal hormones are suspected of contributing to the onset of labor? (Select all that apply.)
1) | Increased oxytocin levels |
2) | Increased prostaglandin levels |
3) | Reduced progesterone levels |
4) | Increased cortisol levels |
5) | Uterine stretch theory |
Chapter 9: Nursing Care During Labor and Childbirth
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Safe Maternity Nursing Care 2nd Ed - Exam Resource Pack
By Luanne Linnard Palmer