Chapter 17 Intrapartum Nursing Assessment

Chapter 17   Intrapartum Nursing Assessment

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

1) The nurse is admitting a patient to the labor and delivery unit. Which aspect of the patient’s history requires notifying the physician?

1. Blood pressure 120/88
2. Father is a carrier of sickle-cell trait
3. Dark red vaginal bleeding
4. History of domestic abuse

Answer:  3

Explanation:  1. Blood pressure 120/88. Although the diastolic reading is slightly elevated, this is not the top priority.

2. The infant also might have sickle trait, but sickle trait is not life-threatening at this time.
3. Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and fetus.
4. This patient is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the patient.

Page Ref: 336

Cognitive Level:  Application

Client Need&Sub:  Health Promotion and Maintenance

Standards:  QSEN Competencies: Teamwork and collaboration | AACN Essential Competencies: Essential VI: Interprofessional communication and collaboration for improving patient health outcomes | NLN Competencies: Nursing judgement | Nursing/Integrated Concepts: Nursing Process: Assessment/Collaboration

Learning Outcome:  LO 17.1-Describe a maternal assessment of the laboring woman that includes the patient history, high-risk screening, and physical and psychosociocultural factors.

MNL LO:  Contrast the bleeding disorders of late pregnancy and their implications for nursing care.

 

2) The nurse is preparing to assess a laboring primiparous client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed?

1. “You are going to do a vaginal exam to see how far dilated my cervix is.”
2. “The reason for a pelvic exam is to determine how low in the pelvis my baby is.”
3. “When you check my cervix, you will find out how thinned out it is.”
4. “After you assess my pelvis, you will be able to tell when I will deliver.”

Answer:  4

Explanation:  1. Cervical dilation is one aspect of the pelvic exam assessment.

2. Determining the station of the presenting part is one aspect of the pelvic exam assessment.
3. Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam assessment.
4. An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about the contractions. The nurse will not have enough information following the cervical exam to estimate time of birth.

Page Ref: 340

Cognitive Level:  Analyzing

Client Need&Sub:  Health Promotion and Maintenance

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential VII: Clinical prevention and population health | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Evaluation/Health teaching

Learning Outcome:  LO 17.2-Evaluate the progress of labor by assessing the laboring woman’s contractions, cervical dilatation, and effacement.

MNL LO:  Discuss the phases and stages of labor including factors that affect labor progress.

 

 

3) The nurse is working with a pregnant adolescent. The client asks the nurse how the baby’s condition is determined during labor. Which statement indicates the client education was successful? “During labor, the nurse will:

1. “Check your cervix by doing a pelvic exam every two hours.”
2. “Assess the baby’s heart rate with an electronic fetal monitor.”
3. “Look at the color and amount of bloody show that you have.”
4. “Verify that your contractions are strong but not too close together.”

Answer:  2

Explanation:  1. Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal status. The client has asked specifically about assessing fetal status in labor.

2. This option best answers the question the client has asked.
3. Although bloody show is monitored, doing so does not assess fetal status. The client has asked specifically about assessing fetal status in labor.
4. Although contraction strength is palpated abdominally, the client has asked about assessing fetal status in labor.

Page Ref: 345-348

Cognitive Level:  Application

Client Need&Sub:  Health Promotion and Maintenance

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential VII: Clinical prevention and population health | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Planning/Health teaching and health promotion

Learning Outcome:  LO 17.3-Describe an intrapartum fetal assessment to determine fetal position and presentation, fetal heart rate, and fetal status.

MNL LO:  Examine the nursing assessments associated with each stage/phase of labor.

 

4) The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first?

1. Perform Leopold’s maneuver to determine fetal position.
2. Count the fetal heart rate for 30 seconds and multiply by two.
3. Dry the maternal abdomen before using the Doppler.
4. Place the patient into a left lateral position.

Answer:  1

Explanation:  1. This is the first step so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided.

2. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold’s maneuver to determine fetal position so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided.
3. Prior to using the Doppler device, a water-based gel is applied to the skin.
4. The fetal heart tone assessment should be performed while the patient is either supine with a lateral tilt or while in left lateral position. Leopold’s maneuver is performed first to determine where to listen for fetal heart tones.

Page Ref: 342-344

Cognitive Level:  Application

Client Need&Sub:  Health Promotion and Maintenance

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential VII: Clinical prevention and population health | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Assessment/Coordination of care

Learning Outcome:  LO 17.4-Describe the steps and frequency for performing auscultation of fetal heart rate.

MNL LO:  Examine the nursing assessments associated with each stage/phase of labor.