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Chapter 12: The Process of Labor and Birth MULTIPLE CHOICE 1)The perinatal nurse is assessing a woman at 36 weeks gestation

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Chapter 12: The Process of Labor and Birth MULTIPLE CHOICE

1)The perinatal nurse is assessing a woman at 36 weeks gestation. Her fundal height measurement was last recorded at 34 cm. The patients abdomen appears to be widest from side to side. The nurse suspects the possibility of which type of fetal presentation?

1. 1. Breech
   2. Cephalic
   3.             Face
   4.             Shoulder

 

2.         The perinatal nurse assessing a laboring womans contraction intensity by internal monitoring would expect, during the transition phase, a reading in which of the following ranges?

A.        10 to 12 mm Hg

B.        20 to 40 mm Hg

C.        50 to 70 mm Hg

D.        70 to 90 mm Hg

 

3.         The perinatal nurse knows that when the fetal head is fully extended and the occiput is near the spine, the delivery team should prepare for the presenting fetal part to be which of the following?

A.        Brow

B.        Chin

C.        Face

D.        Sacrum

 

4.         The perinatal nurse describes different breech positions to the student nurse. The fetal position with extended legs toward the fetal shoulders is best described as which of the following?

A.        Complete breech

B.        Footling breech

C.        Frank breech

D.        Incomplete breech

 

5.         The perinatal nurse is describing the process of fetal engagement to a group of first-time parents in a prenatal class. The nurse explains that in primigravidas, the usual time for engagement to occur is which of the following?

A.        2 weeks before the due date

B.        4 weeks before the due date

C.        6 weeks before the due date

D.        During labor

 

6.         A nurse is measuring the frequency of a laboring womans contractions. How does the nurse accomplish this correctly?

A.        Counts the number of contractions measured at the same intensity in 1 full minute

B.        Feels the fundus during the acme of the contraction and notes the fundal firmness

C.        Measures the beginning of one contraction to the beginning of the next contraction

D.        Measures the time from the beginning of one contraction to the end of the same contraction

 

7.         A patients cervix is 8 cm dilated and she is 100% effaced. What action by the nurse is most important at this time?

A.        Allow the support person to be at the bedside.

B.        Encourage the woman to bear down.

C.        Have the woman avoid pushing at this time.

D.        Instruct the woman to rest between contractions.

 

8.         A nurse reads in a womans chart that the fetus is in a longitudinal lie. What can the nurse conclude about this situation?

A.        The fetal head is flexed prior to delivery.

B.        The fetal head-to-tailbone axis is at a 90 angle to the womans head-to-tailbone axis.

C.        The fetal head-to-tailbone axis is the same as the womans head-to-tailbone axis.

D.        Vaginal birth will be very difficult.

 

9.         At 9:00 a.m., the OB nurse assesses fetal station at 0. The laboring woman has strong, regular contractions. At 10:30 a.m., the nurse again assesses fetal station at 0. What action by the nurse is best?

A.        Document the findings and continue to assess frequently.

B.        Encourage the woman to bear down during contractions.

C.        Increase the womans IV fluid rate and reassess in 30 minutes.

D.        Inform the provider and prepare for possible cesarean delivery.

 

10.       A nurse assesses the fetal position in a laboring woman. The fetal position is documented as LSP. What action by the nurse is best?

A.        Continue to support the womans labor efforts.

B.        Document the findings in the womans chart.

C.        Inform the provider; prepare for possible cesarean delivery.

D.        Turn the woman on her left side; reassess in 30 minutes.

 

11.       A woman who is 40 weeks pregnant calls the clinic to report that she noted a small amount of blood-tinged mucus on her toilet tissue this morning. What response by the nurse is most appropriate?

A.        Come to the clinic today for an examination.

B.        Labor will probably start within 48 hours.

C.        Lie on your left side and count fetal kicks.

D.        Stay on bedrest until your labor begins.

 

12.       A woman arrives at the birthing unit complaining of frequent strong contractions that begin in her back and cannot be relieved by walking or changing positions. What action by the nurse is most appropriate?

A.        Assess the woman for rupture of membranes.

B.        Immediately notify the womans primary care provider.

C.        Reassure the woman and send her home.

D.        Review the signs of true labor with the woman.

 

13.       A woman in the perinatal clinic reports a gush of vaginal fluid after sneezing. The nurse performs a Nitrazine tape test and documents that the tape is beige in color. What action should the nurse take?

A.        Ask the woman about recent sexual intercourse.

B.        Assess the woman for urinary incontinence.

C.        Arrange for the woman to be admitted to the birthing unit.

D.        Inquire if the woman has symptoms of a vaginal infection.

 

14.       A woman and her partner are interested in exploring different birthing options. What action by the perinatal nurse would be most helpful?

A.        Advise the couple to ask for referrals from friends.

B.        Arrange tours of different birthing facilities.

C.        Give the couple brochures from different facilities.

D.        Refer to social work for an insurance review.

 

15.       A womans birthing plan includes completing the latent phase of the first stage of labor at home. When should the nurse teach the woman to come in to the birthing unit?

A.        After 10 hours of mild contractions

B.        When contractions are 3 to 5 minutes apart

C.        When contractions are experienced in the back

D.        When strong contractions occur 2 to 3 minutes apart

 

16.       The nurse assesses a woman in labor and finds that her cervix is dilated to 9 cm. The nurse documents the woman to be in what phase of labor?

A.        First stage

B.        Second stage

C.        Third stage

D.        Fourth stage

 

17.       A nulliparous woman in labor is 3 cm dilated at 10:00

a.m. Based on knowledge of the average nulliparous womans progression, when would the nurse expect her to be fully dilated?

A. 12:00 p.m.

B. 2:00 p.m.

C. 5:00 p.m.

D. 10:00 p.m.

 

18.       A husband in the labor suite is concerned that as his wifes labor progresses, she has become distant, is not interested in conversation, and, at times, is short with him. Which response by the nurse is best?

A.        Dont worry; women often get this way during labor.

B.        Maybe if you step out for a while, shell feel better.

C.        She must concentrate to cope with her labor.

D.        This is a difficult period; it will be over shortly.

 

19.       A woman is in the early latent phase of labor and is frustrated by the length of time this stage is taking. What action by the nurse is best?

A.        Administer 100% oxygen by face mask.

B.        Encourage frequent position changes or walking.

C.        Have the woman rest between contractions.

D.        Place the woman in a left side-lying position.

 

20.       A woman in labor seems to be progressing more slowly than expected. Which action should the nurse perform first?

A.        Administer oxygen by face mask.

B.        Assess the woman for a full bladder.

C.        Increase the rate of the IV fluids.

D.        Provide stimulants such as coffee.

 

21.       A new nurse is caring for a woman in the transition phase of labor. The nurse attempts to engage the woman in conversation and chats even when the woman doesnt respond to these attempts. What action by the nurses preceptor is most appropriate?

A.        Direct the nurse to attempt conversation with the support person.

B.        Encourage the nurse to keep attempting to engage the woman in conversation.

C.        Gently ask the nurse to refrain from unnecessary conversation.

D.        Tell the nurse not to take the womans silence as a personal rejection.

 

22.       A nurse is assessing a woman in labor. In order to assess the fetal position most accurately, which of the following methods should be used?

A.        Auscultation of fetal heart tones

B.        Leopold maneuvers

C.        Ultrasound examination

D.        Vaginal examination

 

23.       A nurse assessing fetal heart tones hears them best below the level of the maternal umbilicus. What type of fetal presentation would this nurse expect?

A.        Breech

B.        Cephalic

C.        Footling

D.        Shoulder

 

24.       A woman with a history of two stillbirths is in the active phase of the first stage of labor in the high-risk OB unit. How often should the nurse anticipate monitoring fetal heart tones (FHTs)?

A.        Continuously

B.        Every 5 minutes

C.        Every 15 minutes

D.        Every 30 minutes

 

25.       A nurse has assessed baseline fetal heart tones (FHTs) by auscultation and documents a funic souffl of 158 beats/minute and a uterine souffl of 90 beats/minute. When the first nurse gives a handoff report to an oncoming nurse, what can the second nurse conclude from this information?

A.        Fetal and maternal heart rates are outside of normal limits.

B.        Fetal and maternal heart rates are within normal limits.

C.        The second nurse cannot distinguish between fetal and maternal heart rates.

D.        There is a great deal of fetal heart rate variability between contractions.

 

26.       A new nurse is assessing baseline fetal heart tones (FHTs) by auscultation and notes that the heart rate increased during a contraction from 140 to 158. What action by the nurse preceptor is best?

A.        Gather equipment for internal FHT monitoring.

B.        Have the nurse document FHT of 140/158.

C.        Instruct the nurse to assess FHT between contractions.

D.        Tell the nurse to count only for 30 seconds.

 

27.       A nurse assesses the fetal heart rate at 188 beats/minute in a woman who is receiving a tocolytic medication to halt contractions. Which action should the nurse take first?

A.        Assess the maternal temperature and call the primary care provider.

B.        Document the findings in the patients chart.

C.        Have the woman get up and walk or change position.

D.        Perform a vaginal exam to assess for cord compression.

 

28.       A nurse assesses fetal heart tones at 100 beats/minute. Which action by the nurse takes priority?

A.        Administer 100% oxygen.

B.        Assess the maternal heart rate.

C.        Notify the primary care provider.

D.        Turn the woman on her left side.

 

29.       The OB nurse assesses moderate baseline variability on the fetal heart monitor. What action by the nurse is best?

A.        Administer a bolus of IV fluids.

B.        Discontinue oxytocin, if it is being delivered.

C.        Document the findings in the womans chart.

D.        Perform fetal scalp or vibroacoustic stimulation.

 

30.       A nurse assessing a fetal heart monitor notes minimal baseline variability not associated with a fetal sleep cycle.

There is no change after fetal scalp stimulation. What action by the nurse is most important?

A.        Administer a bolus of IV fluids.

B.        Administer oxygen at 810 L/min per mask.

C.        Offer support to the patient and her partner.

D.        Prepare to assist with internal fetal monitoring.

 

31.       A nurse notes fetal heart rate decelerations that appear to start just prior to a uterine contraction with the fetal heart rate returning to normal by the end of the contraction. How does the nurse document this finding?

A.        Early deceleration

B.        Late deceleration

C.        Mild deceleration

D.        Variable deceleration

 

32.       A nurse assessing a woman in labor notes late decelerations on the fetal monitor and documents contractions occurring every 1 to 2 minutes. Oxytocin (Pitocin) is being infused IV, and oxygen is being delivered at 8 L/min per mask. The woman is positioned on her left side. What action by the nurse takes priority?

A.        Discontinue the oxygen.

B.        Increase the oxytocin rate.

C.        Assist the woman to a supine position.

D.        Stop the oxytocin infusion.

 

33.       A new nurse is preparing to assess the fetal heart rate response to stimulation with vibroacoustic stimulation. What action by the new nurse would prompt the precepting nurse to intervene?

A.        Nurse attempts stimulation in the presence of fetal bradycardia.

B.        Nurse attempts stimulation in the presence of ruptured membranes.

C.        Nurse places stimulation device over the fetal head for 1 to 2 seconds.

D.        Nurse waits until fetal heart rate is at baseline before initiating the stimulation.

 

34.       A nurse is caring for a woman in labor whose fetal heart rate tracings show late decelerations. What observation by the nurse indicates that an important outcome for the nursing diagnosis of impaired fetal gas exchange has been met?

A.        Fetal heart monitor shows accelerations to contractions.

B.        Fetal heart monitor shows variable decelerations.

C.        Fetal heart rate rises to180 beats/minute.

D.        Maternal heart rate returns to baseline between contractions.

 

35.       A nurse suspects that a laboring woman has entered the second stage of labor by what assessment?

A.        Cervix is more than 50% dilated.

B.        Contractions are more frequent.

C.        Contractions are more intense.

D.        Woman has a strong urge to push.

 

36.       During the second stage of labor, a nurse encourages effective pushing by the woman. What directions from the nurse best achieve this?

A.        Hold your breath and push as hard as you can.

B.        Now that you are fully dilated, start pushing.

C.        Push when you feel the urge and breathe between attempts.

D.        When you feel a contraction, push with your mouth closed.

 

37.       A nurse notes a perineal laceration that extends into the rectal mucosa after a woman gives birth to a full-term baby. How does the nurse document this information?

A.        First-degree  laceration

B.        Second-degree laceration

C.        Third-degree laceration

D.        Fourth-degree laceration

 

38.       What nursing action best helps to prevent perineal lacerations during birth?

A.        Providing adequate coaching on pushing and breathing

B.        Applying warm compresses to the perineum

C.        Helping the woman to squat during labor

D.        Performing an episiotomy early in labor

 

39.       The nurse explains to the class of nursing students that umbilical cord clamping occurs at what time after birth?

A.        Immediately

B.        After 15 seconds

C.        After 30 to 60 seconds

D.        After 60 to 120 seconds

 

40.       What important nursing action occurs right after the third stage of labor?

A.        Assess the placenta for complete expulsion.

B.        Assist the woman with effective pushing.

C.        Provide a lactation consultation if desired.

D.        Warm the baby and place it in an incubator.

 

41.       A nurse is caring for a new mother during the fourth stage of labor and assesses the following: patient has soaked two peri-pads in 45 minutes, pulse is 118 beats/minute, and blood pressure is 90/62 mm Hg. Which action by the nurse is most important?

A.        Assess the firmness of the patients uterus.

B.        Document the findings and reassess in 15 minutes.

C.        Encourage the woman to attempt breastfeeding.

D.        Escort the woman to the bathroom to void.

 

42.       A woman who is 37 weeks pregnant calls the birthing center to report a gush of clear fluid from her vagina. What response by the nurse is best?

A.        Are you having any pain?

B.        Come in now to be evaluated.

C.        Did you have any trauma?

D.        It is too early for membrane rupture.

 

MULTIPLE RESPONSE

 

1.         The nurse in the birthing unit is aware that according to the Emergency Medical Treatment and Active Labor Act (EMTALA), pregnant women should receive care for problems such as which of the following? (Select all that apply.)

A.        A history of recent trauma

B.        Contractions that occur 20 minutes apart

C.        Decreased fetal movement

D.        Rupture of the membranes

E.        Sexually transmitted infections

 

2.         When calling the primary health-care provider regarding a womans admission, the perinatal nurse includes which of the following information? (Select all that apply.)

A.        Gestational age and estimated date of birth

B.        Maternal and fetal vital signs

C.        Presence of support person(s)

D.        Status of other children

E.        Status of the fetal membranes

 

3.         The perinatal nurse knows that changes in the pelvic floor musculature that normally occur in labor include which of the following? (Select all that apply.)

A.        Eversion of the anus

B.        Exposure of the internal rectal wall

C.        Pulling downward on the levator ani muscles

D.        Rectum drawn upward and backward

E.        Thinning of the perineal body

 

4.         The perinatal nurse describes normal maternal signs and symptoms associated with lightening to the prenatal class attendants. These signs and symptoms include which of the following? (Select all that apply.)

A.        Difficulty breathing

B.        Increased urinary frequency

C.        Increased vaginal secretions

D.        Leg cramps

E.        Nausea and vomiting

 

5.         The perinatal nurse describes prelabor or Braxton Hicks contractions to the prenatal class attendants as which of the following? (Select all that apply.)

A.        Contributing to cervical effacement and dilation

B.        Felt in the abdomen or groin

C.        Intensely painful

D.        Irregular

E.        Regular and progressive

 

6.         The perinatal nurse obtains valuable information from a vaginal examination. Which of the following assessments from this examination should the nurse document? (Select all that apply.)

A.        Extent of cervical dilation

B.        Fetal presentation

C.        Presence of cervical effacement

D.        Status of the amniotic membranes

E.        Strength of uterine contractions

 

7.         A woman is admitted in labor. The perinatal nurse would demonstrate cultural sensitivity by assessing the patient for which of the following? (Select all that apply.)

A.        Need for an interpreter

B.        Pain management and coping techniques

C.        Preference for food during labor

D.        Preferences for touch during labor

E.        Support person during labor

 

8.         The perinatal nurse knows that a cephalic presentation has which of the following advantages to the woman in labor? (Select all that apply.)

A.        Fetal skull bones have the ability to mold during birth.

B.        The largest part of the fetus is presenting first.

C.        The presenting part may not totally cover the cervix.

D.        The shape of the fetal head is optimal for cervical dilatation.

E.        The top of the fetal head assists with cervical effacement.

 

9.         A nursing instructor explains to the class of nursing students that the critical factors affecting the progress of labor include which of the following? (Select all that apply.)

A.        Passageway

B.        Passageway + Passenger

C.        Passenger

D.        Productivity

E.        Psychosocial factors

 

10.       The nurse instructs the pregnant woman to report any rupture of the membranes along with a description of the fluid. Which of the following would the nurse evaluate as normal amniotic fluid? (Select all that apply.)

A.        Clear liquid

B.        Contains white specks

C.        Presence of lanugo

D.        Slight ammonia odor

E.        Yellow-greenish color

 

11.       A young girl in active labor arrives at the hospital without having had any prenatal care. She is extremely anxious and crying out in pain. What would the nurse assess to best determine that goals for the diagnosis of knowledge deficit have been met? (Select all that apply.)

A.        Begs her mother to stay with her while giving birth

B.        Can describe expected labor progress and states she is in less pain

C.        Is able to cooperate with breathing instructions during contractions

D.        Is able to give a history of this pregnancy to the admitting nurse

E.        States that after this birth, she wants to learn about birth control

 

 

12.       The nurse is assessing a woman in labor. What techniques are vital for the nurse to use during this assessment? (Select all that apply.)

A.        Auscultation

B.        Inspection

C.        Interviewing

D.        Percussion

E.        Palpation

 

13.       A nurse notes variable decelerations on the fetal heart monitor and is explaining them to the laboring woman and her partner. What information about these patterns does the nurse share? (Select all that apply.)

A.        Last at least 15 seconds

B.        Least common type of deceleration pattern

C.        May be a result of cord compression

D.        Occur at any time during a contraction

E.        Return to baseline within 4 minutes

 

14.       A nurse is assisting with an amnioinfusion. What critical nursing actions are included in this procedure? (Select all that apply.)

A.        Assessing the maternal temperature

B.        Assembling  equipment

C.        Documenting fluid exiting the vagina

D.        Maintaining sterile technique

E.        Monitoring the fetal heart rate

 

15.       The nurse assessing a woman in the third stage of labor would expect which of the following findings? (Select all that apply.)

A.        Cramping as the placenta delivers

B.        Mother crying or feeling relieved

C.        Presence of lochia rubra with small clots possible

D.        Uterus rises upward

E.        Vital signs returning to prelabor values

 

16.       The faculty member teaching a class of students explains several theories regarding the onset of labor. Which of the following does the faculty member include? (Select all that apply.)

A.        Closure of ductus arteriosus

B.        Molding of the fetal head

C.        Placental aging

D.        Pressure on the cervix

E.        Uterine muscle stretching

 

17.       Place the following cardinal movements in the order in which they occur as a fetus passes through the birth canal during a vertex-presentation birth.

A.                    Flexion

B.                    External rotation

C.                    Descent

D.                    Extension

E.                    Restitution

F.                     Internal rotation

G.                    Expulsion

 

The order of the cardinal movements (mechanisms of labor) occur as follows: descent, flexion, internal rotation, extension, restitution, external rotation, expulsion.

 

18.       A nurse assesses a newborn as follows: heart rate is 112 beats/minute; respiratory effort: slow, irregular, with a weak cry; muscle tone: some flexion of the extremities; reflex irritability: grimace; color: pink. What Apgar score does the nurse give this infant?