Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig)

Chapter 21 The Family in Childbirth: Needs and Care

1. The laboring client is at 7 c m, 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 client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client?
2. Fear/Anxiety related to discomfort of labor and unknown labor outcome
3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent
4. Coping: Family, Compromised, related to labor process
5. Knowledge, Deficient, related to lack of information about normal labor process and comfort measures

Page Ref: 498

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's 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.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. 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 c m 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?
2. Latent phase
3. Active phase
4. Transition phase
5. Fourth stage

Page Ref: 504

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N 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.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse is assessing the comfort of the parents during the third stage of labor. Which finding(s) indicate that the parents feel comfortable during this stage?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Talking to the newborn
2. Verbally expressing feelings of pride
3. Requesting to dim the lights
4. Preferring limited contact with the newborn initially
5. Immediately placing phone calls

Page Ref: 519

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 8 Discuss the components of care for the woman during the third stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse is caring for a client and her spouse during the third stage of labor. Which action(s) support initial parental-newborn attachment at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Minimizing assessments
2. Delaying ophthalmic antibiotics for 2 hours
3. Dimming the room lights
4. Talking quietly
5. Providing privacy

Page Ref: 519

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 9 Discuss initial measures to help the woman and family integrate the newborn into family life.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse is assessing the emotional state of a client following the delivery of her newborn. Which response by the client requires further follow up by the nurse?
2. Excitability
3. Crying
4. Quiet
5. Withdrawn

Page Ref: 519

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N 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. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 9 Discuss initial measures to help the woman and family integrate the newborn into family life.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include 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. Fetal heart rate of 130 with average variability
2. Blood pressure of 130/80
3. Maternal pulse of 160
4. Protein of +1 in urine
5. Odorless, clear fluid on underwear

Page Ref: 500

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N 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. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching?
2. "The fetus's heart rate will vary between 110 and 160."
3. "The heart rate is monitored to see whether the fetus is tolerating labor."
4. "By listening to the heart, we can tell the gender of the fetus."
5. "After listening to the heart rate, you will contact the midwife."

Page Ref: 500

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first?
2. The sterile vaginal exam
3. Welcoming the couple
4. Auscultation of the fetal heart rate
5. Checking for ruptured membranes

Page Ref: 507

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N 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. | N L N 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.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be which of the following?
2. Insist that he leave the room for at least the next hour.
3. Tell him he is not being as effective as he was, and that he needs to let someone else take over.
4. Offer to remain with his partner while he takes a break.
5. Suggest that the client's mother might be of more help.

Page Ref: 527

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Support Systems

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following?
2. Recognizing the client as an active participant in her own care.
3. Attempting to correct any misinformation the client might have received.
4. Acting as an advocate for the client.
5. Establishing rapport with the client.

Page Ref: 499

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 4 Summarize the importance of incorporating family expectations and cultural beliefs into the nursing care plan.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. "These questions are asked of all women. It's no big deal."
2. "I'd prefer that your partner ask me all the questions, not you."
3. "A client's preferences for her birth are important for me to understand."
4. "Many women have beliefs about childbearing that affect these choices."
5. "I'm gathering information that the nurses will use after the birth."

Page Ref: 502

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 4 Summarize the importance of incorporating family expectations and cultural beliefs into the nursing care plan.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be?
2. Check fetal heart tones.
3. Encourage the mother to go for a walk.
4. Change bed linens.
5. Call the physician.

Page Ref: 503

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 c m and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority?
2. Encourage the husband to remain in the room.
3. Keep the client on bed rest at this time.
4. Apply an internal fetal scalp electrode.
5. Obtain a clean-catch urine specimen.

Page Ref: 506

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client?
2. Encourage the client to vocalize during contractions.
3. Perform vaginal exams only between contractions.
4. Provide a C D of soft music with sounds of nature.
5. Offer to teach the partner how to massage tense muscles.

Page Ref: 508

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse is reviewing the contents of the birthing unit's emergency pack for use in case of a precipitous birth. Which item(s) should the nurse ensure is (are) included in the pack?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Sterile drape
2. Bulb syringe
3. Two sterile clamps
4. Sterile gloves
5. Forceps

Page Ref: 525

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 11 Delineate management of a nurse-managed precipitous labor and birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take?
2. Massage the fundus until firm
3. Express retained clots
4. Increase the intravenous solution
5. Call the physician

Page Ref: 521

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently?
2. A full bladder impedes oxygen flow to the fetus.
3. Frequent voiding prevents bruising of the bladder.
4. Frequent voiding encourages sphincter control.
5. A full bladder can impede fetal descent.

Page Ref: 504

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following?
2. Hyperventilation
3. Seizure auras
4. Imminent birth
5. Anxiety

Page Ref: 508

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful?
2. Talk to the client the entire time.
3. Turn on the television to distract the client.
4. Stand next to the bed with hands on the railing next to the client.
5. Sit silently in the room away from the bed.

Page Ref: 527

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done?
2. To contract the uterus and minimize bleeding
3. To decrease breast milk production
4. To decrease maternal blood pressure
5. To increase maternal blood pressure

Page Ref: 520

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety, and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention?
2. A soaked perineal pad since the last 15-minute check
3. An edematous perineum
4. The client experiencing tremors
5. A fundus located at the umbilicus

Page Ref: 523

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score?
2. 7
3. 8
4. 9
5. 10

Page Ref: 517

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply?
2. "I'm checking the blood vessels in the cord to see whether it has one artery and one vein."
3. "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein."
4. "I'm checking the blood vessels in the cord to see whether it has two veins and one artery."
5. "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins."

Page Ref: 518

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score?
2. 7
3. 8
4. 9
5. 10

Page Ref: 517

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 8. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. Upon delivery of the newborn, what nursing intervention most promotes parental attachment?
2. Placing the newborn under the radiant warmer.
3. Placing the newborn on the mother's abdomen.
4. Allowing the mother a chance to rest immediately after delivery.
5. Taking the newborn to the nursery for the initial assessment.

Page Ref: 519

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: Q S E N Competencies: Ⅰ. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 8 Discuss the components of care for the woman during the third stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action?
2. Determine who might be the father of the baby for paternity testing.
3. Ask the client what kind of birthing experience she would like to have.
4. Assess blood pressure and check for proteinuria.
5. Obtain a Social Services referral to discuss adoption.

Page Ref: 523

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 10 Explore the nurse's role in providing sensitive, developmentally responsive care to adolescent parents.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following?
2. Cultural background
3. Plans for keeping the infant
4. Support persons
5. Developmental level

Page Ref: 523

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: Q S E N Competencies: Ⅰ. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 10 Explore the nurse's role in providing sensitive, developmentally responsive care to adolescent parents.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include 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. Skin color: Body blue with pinkish extremities
2. Umbilical cord: two veins and one artery
3. Respiration rate of 30-60 irregular
4. Temperature of above 36.5°C (97.8°F)
5. Sole creases that involve the heel

Page Ref: 518

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do?
2. Go to the nurse's station and immediately call the physician.
3. Run to the delivery room for an emergency birth pack.
4. Stay with the client and ask auxiliary personnel for assistance.
5. Hold back the infant's head forcibly until the physician arrives for the delivery.

Page Ref: 525

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 20. Understand one's role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks they pose to self and patients. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 11 Delineate management of a nurse-managed precipitous labor and birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse has completed an initial physical assessment for a client admitted to the birthing unit. Which action should the nurse take next?
2. Obtain the client's social history
3. Document the physical assessment findings
4. Report findings to the physician
5. Perform interventions for pain management

Page Ref: 501

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Discuss the components of a social history and its function in caring for the laboring woman.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse has taken a detailed social history from a client admitted to the birthing unit. Which insights may the nurse gain as a result of this assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Social habits
2. Psychologic factors
3. Presence of H I V
4. Readiness for discharge
5. Need for bed rest

Page Ref: 501

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment.

Learning Outcome: 3 Discuss the components of a social history and its function in caring for the laboring woman.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. A newborn has the following applied to the umbilical cord.

What should the nurse instruct the new parents about regarding this device?

1. It has to stay intact for at least one week
2. It is removed in 24 hours if the cord has dried
3. It eliminates the need to wash the infant's abdomen
4. It is removed by cutting the tissue beneath the clamp

Page Ref: 515

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse determines that a newborn has the following findings:

Heart rate: 88 beats per minute

Respirations: 24 per minute and irregular

Muscle tone: Minor movement of lower extremities

Reflex response: Grimace

Skin color: Pink body, blue extremities

If using the following table, what action should the nurse take at this time?

Table 21-5 The Apgar Scoring System

Source: Data from Apgar, Ⅴ. (1966).

1. Begin resuscitation
2. Stimulate the infant
3. Document the findings
4. Nasopharyngeal suctioning

Page Ref: 517

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process.

Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.

1. The nurse is observed performing the following with a patient:

What information will this assessment technique provide to the nurse?

1. Assesses for bladder distention
2. Estimates the weight of the uterus
3. Determines the height of the fundus
4. Evaluates the remaining placenta contents

Page Ref: 522

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment; Nursing Process.

Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor.

M N L L O: Demonstrate use of the nursing process in the care of the family in childbirth.