Chapter 21 Intrapartum Nursing Assessment

Chapter 21   Intrapartum Nursing Assessment

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

1) The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client’s psychosocial status?

1. “How did you decide to have your baby at this hospital?”
2. “Who will be your labor support person?”
3. “Have you chosen names for your baby yet?”
4. “What feeding method will you use for your baby?”

Answer:  2

Explanation:  2. The expectant mother’s partner or support person is an important member of the birthing team, and assessments of the couple’s coping, interactions, and teamwork are integral to the nurse’s knowledge base. The nurse’s physical presence with the laboring woman provides the best opportunity for ongoing assessment.

Page Ref: 469

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:  1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO:  3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

 

 

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

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

Answer:  3

Explanation:  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 mother and fetus.

Page Ref: 473

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:  1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO:  3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

3) The nurse is working with a pregnant adolescent. The client asks the nurse how the baby’s condition is determined during labor. The nurse’s best response is that during labor, the nurse will do which of the following?

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

Answer:  2

Explanation:  2. This statement best answers the question the client has asked.

Page Ref: 480

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:  1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO:  3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

 

4) During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client’s partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Uterine contraction pattern
2. Fetal position
3. Presence of the mucous plug
4. Cervical dilation and effacement
5. Presenting part

Answer:  4, 5

Explanation:  4. The vaginal examination of a laboring client obtains information about the station of the presenting part and the dilation and effacement of the cervix.

5. The vaginal examination of a laboring client obtains information about the fetal presenting part.

Page Ref: 483

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:  1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO:  3.1.4 Examine the nursing assessments associated with each stage/phase of labor.

 

5) A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Check for ruptured membranes and apply a fetal scalp electrode.
2. Auscultate the fetal heart rate between and during contractions.
3. Palpate contractions and resting uterine tone.
4. Assess the blood pressure, temperature, respiratory rate, and pulse rate.
5. Perform a vaginal exam for cervical dilation, and perform Leopold maneuvers.

Answer:  2, 3

Explanation:  2. Fetal heart rate auscultation gives information about the physical status of the fetus.

3. Contraction palpation provides information about the frequency, duration, and intensity of the contractions.

Page Ref: 481, 487

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:  1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome.

MNL LO:  3.1.4 Examine the nursing assessments associated with each stage/phase of labor.