Chapter 13: Nursing Care During Labor and Birth

Chapter 13: Nursing Care During Labor and Birth

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The nurse is preparing to perform Leopold’s maneuvers. Why are Leopold’s maneuvers used by practitioners?

ANS:  C

Leopold’s maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

PTS:   1                    DIF:    Cognitive Level: Application           REF:   227

OBJ:   Nursing Process Step: Planning        MSC:  Client Needs: Health Promotion and Maintenance

2. Which comfort measure should a nurse use to assist a laboring woman to relax?

ANS:  A

Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

PTS:   1                    DIF:    Cognitive Level: Application           REF:   236

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

3. Which assessment finding could indicate hemorrhage in the postpartum patient?

ANS:  A

An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

PTS:   1                    DIF:    Cognitive Level: Analysis                REF:   224

OBJ:   Nursing Process Step: Assessment   MSC:  Client Needs: Physiologic Integrity

4. Which is an essential part of nursing care for a laboring client?

ANS:  A

Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

PTS:   1                    DIF:    Cognitive Level: Application           REF:   220

OBJ:   Nursing Process Step: Planning        MSC:  Client Needs: Health Promotion and Maintenance

5. A client at 40 weeks’ gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:

ANS:  C

A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

PTS:   1                    DIF:    Cognitive Level: Application           REF:   221

OBJ:   Nursing Process Step: Implementation

MSC:   Client Needs: Physiologic Integrity