Safe Maternity Pediatric Nursing By Care Palmer Coats
Safe Maternity Pediatric Nursing By Care Palmer Coats
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Chapter 10: Nursing Care During Labor
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. 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, Rh, 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 |
____ 2. A patient is in active labor, 6 cm dilated, 100% effaced with intact amniotic membranes. Which procedure does the nurse anticipate?
| 1) | Amniotomy |
| 2) | Episiotomy |
| 3) | Amnioinfusion |
| 4) | Intermittent fetal monitoring |
____ 3. 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 |
____ 4. A woman in active labor has not progressed since reaching 6 cm dilation. Which is the nurse’s priority of care?
| 1) | Assisting with bladder emptying |
| 2) | Administering analgesics |
| 3) | Encouraging and reinforcing relaxation and breathing |
| 4) | Encouraging position changes |
Answer Section
MULTIPLE CHOICE
Chapter number and title: 10: Nursing Care During Labor
Chapter learning objective: Explain medical interventions that may occur during each stage of labor.
Chapter page reference: 137-138
Heading: Early or Latent Phase of Labor
Integrated processes: Clinical Problem-Solving Process
Client need: Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Pregnancy
Difficulty: Difficult
| Feedback | |
| 1 | There is no need to question an order to start an IV of lactated Ringer’s in the latent phase of labor. |
| 2 | A CBC, blood type, Rh, and urinalysis are routinely done in the latent phase of labor, so there is no need to question this order. |
| 3 | The nurse should question the order to prepare for an amniotomy because this is not routinely done in the latent phase of labor. |
| 4 | The order for penicillin G is standard practice for treating a woman with group B Streptococcus infection. |
PTS: 1 CON: Pregnancy
Chapter number and title: 10: Nursing Care During Labor
Chapter learning objective: Explain medical interventions that may occur during each stage of labor.
Chapter page reference: 138-139
Heading: Stage 1: Active Phase of Labor
Integrated processes: Clinical Problem-Solving Process
Client need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
| Feedback | |
| 1 | Performance of an amniotomy can be anticipated if the woman is 6 cm dilated and still has intact membranes. |
| 2 | Episiotomy is not performed until birth. |
| 3 | Amnioinfusion is not indicated for this patient and is not anticipated. |
| 4 | Continuous fetal monitoring rather than intermittent fetal monitoring is anticipated for this patient. |
PTS: 1 CON: Pregnancy
Chapter number and title: 10: Nursing Care During Labor
Chapter learning objective: Plan safe and effective patient-centered nursing care for each stage of labor.
Chapter page reference: 141
Heading: Stage 1: Active Phase of Labor: Safety STAT!
Integrated processes: Clinical Problem-Solving Process
Client need: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Pregnancy
Difficulty: Moderate
| Feedback | |
| 1 | Pain assessment is an ongoing expectation for the laboring woman but is not the priority after performance of amniotomy. |
| 2 | Following amniotomy, there is a risk of nuchal cord prolapse, so the priority of care is to measure fetal heart tones to determine the fetal condition. |
| 3 | Assessing cervical dilation is an ongoing implementation throughout labor but is not the priority following amniotomy. |
| 4 | Fluid intake is generally limited to ice chips in the later stage of labor in case a Cesarean section is needed, so this is not the priority of care after an amniotomy. |
PTS: 1 CON: Pregnancy
Chapter number and title: 10: Nursing Care During Labor
Chapter learning objective: Plan safe and effective patient-centered nursing care for each stage of labor.
Chapter page reference: 139
Heading: Patient Teaching Guidelines for Active Labor
Integrated processes: Clinical Problem-Solving Process
Client need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Pregnancy
Difficulty: Difficult
| Feedback | |
| 1 | A full bladder can slow labor progression, so the nurse should assess for a full bladder and assist the patient in urinating. |
| 2 | Analgesics, especially narcotic analgesics, can slow labor progression, so this is not the nurse’s priority of care but may be required depending on the patient’s pain level and birth plan. |
| 3 | Although encouraging and reinforcing relaxation and breathing is an ongoing standard of care throughout labor, it is not the priority of care with this patient. |
| 4 | Although the patient should be encouraged to change positions as needed and for comfort throughout labor, this is not the priority of care. |
PTS: 1 CON: Pregnancy
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