Chapter 10: Nursing Care During Labor

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

 

1. ANS:  3

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

 

2. ANS:  1

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

 

3. ANS:  2

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

 

4. ANS:  1

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