Chapter 19: Nursing Care of the Family During Labor and Birth

Chapter 19: Nursing Care of the Family During Labor and Birth

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor?

a.	“I passed some thick, pink mucus when I urinated this morning.”
b.	“My bag of waters just broke.”
c.	“The contractions in my uterus are getting stronger and closer together.”
d.	“My baby dropped, and I have to urinate more frequently now.”

 

 

ANS:  C

Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.

 

DIF:    Cognitive Level: Understand            REF:   p. 431

TOP:   Nursing Process: Assessment           MSC:  Client Needs: Health Promotion and Maintenance

 

2. When a nulliparous woman telephones the hospital to report that she is in labor, what guidance should the nurse provide or information should the nurse obtain?

a.	Tell the woman to stay home until her membranes rupture.
b.	Emphasize that food and fluid intake should stop.
c.	Arrange for the woman to come to the hospital for labor evaluation.
d.	Ask the woman to describe why she believes she is in labor.

 

 

ANS:  D

Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data. The initial nursing activity should be to gather data about the woman’s status. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular. Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.

 

DIF:    Cognitive Level: Apply                   REF:   p. 434

TOP:   Nursing Process: Assessment           MSC:  Client Needs: Health Promotion and Maintenance

 

3. The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication?

a.	Intrauterine infection
b.	Hemorrhage
c.	Precipitous labor
d.	Supine hypotension

 

 

ANS:  A

When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of the contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.

 

DIF:    Cognitive Level: Apply                   REF:   p. 444

TOP:   Nursing Process: Planning | Nursing Process: Diagnosis

MSC:  Client Needs: Physiologic Integrity

 

4. The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next?

a.	Immediately notify the woman’s primary health care provider.
b.	Prepare to administer an oxytocic to stimulate uterine activity.
c.	Document the findings because they reflect the expected contraction pattern for the active phase of labor.
d.	Prepare the woman for the onset of the second stage of labor.

 

 

ANS:  C

The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse documents these findings in the client’s medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.

 

DIF:    Cognitive Level: Apply                   REF:   p. 436

TOP:   Nursing Process: Implementation     MSC:  Client Needs: Health Promotion and Maintenance