Chapter 16: Nursing Care Of The Family During Labor And Birth Questions And Answers Well Illustrated.
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Chapter 16: Nursing Care of the Family
Institution
Chapter 16: Nursing Care Of The Family
Chapter 16: Nursing Care Of The Family During Labor And Birth Questions And Answers Well Illustrated.
The nurse recognizes that a woman is in true labor when she states:
a. I passed some thick, pink mucus when I urinated this morning.
b. My bag of waters just broke.
c. The con...
Chapter 16: Nursing Care Of The Family
During Labor And Birth Questions And
Answers Well Illustrated.
The nurse recognizes that a woman is in true labor when she states:
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. - correct answer.
ANS: C
Regular, strong contractions with the presence of cervical change indicate that the
woman is experiencing true labor. 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 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.
PTS: 1 DIF: Cognitive Level: Application REF: 402
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
The nurse teaches a pregnant woman about the characteristics of true labor
contractions. The nurse evaluates the womans understanding of the instructions when
she states, True labor contractions will:
a. Subside when I walk around.
b. Cause discomfort over the top of my uterus.
c. Continue and get stronger even if I relax and take a shower.
d. Remain irregular but become stronger. - correct answer. ANS: C
,True labor contractions occur regularly, becoming stronger, lasting longer, and
occurring closer together. They may become intense during walking and continue
despite comfort measures. Typically true labor contractions are felt in the lower back,
radiating to the lower portion of the abdomen. During false labor, contractions tend to be
irregular and felt in the abdomen above the navel. Typically the contractions often stop
with walking or a change of position.
PTS: 1 DIF: Cognitive Level: Application REF: 402
OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and
Maintenance
When a nulliparous woman telephones the hospital to report that she is in labor, the
nurse initially should:
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. - correct answer.
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
the assessment and gather data. 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. 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. Before instructing the woman to come to
the hospital, the nurse should initiate the assessment during the telephone interview.
PTS: 1 DIF: Cognitive Level: Application REF: 402
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
What is an expected characteristic of amniotic fluid?
a. Deep yellow color
b. Pale, straw color with small white particles
c. Acidic result on a Nitrazine test
d. Absence of ferning - correct answer. ANS: B
Amniotic fluid normally is a pale, straw-colored fluid that may contain white flecks of
vernix. Yellow-stained fluid may indicate fetal hypoxia up to 36 hours before rupture of
membranes, fetal hemolytic disease, or intrauterine infection. Amniotic fluid produces an
, alkaline result on a Nitrazine test. The presence of ferning is a positive indication of
amniotic fluid.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 414
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and
Maintenance
When planning care for a laboring woman whose membranes have ruptured, the nurse
recognizes that the womans risk for _________________________ has increased.
a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension - correct answer. ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the
amniotic sac and cause chorioamnionitis and placentitis. Rupture of membranes (ROM)
is not associated with fetal or maternal bleeding. Although ROM may increase the
intensity of contractions and facilitate active labor, it does not result in precipitous labor.
ROM has no correlation with supine hypotension.
Which action is correct when palpation is used to assess the characteristics and pattern
of uterine
contractions?
a. Place the hand on the abdomen below the umbilicus and palpate uterine tone with
the fingertips.
b. Determine the frequency by timing from the end of one contraction to the end of the
next contraction.
c. Evaluate the intensity by pressing the fingertips into the uterine fundus.
d. Assess uterine contractions every 30 minutes throughout the first stage of labor. -
correct answer. ANS: C
The nurse or primary care provider may assess uterine activity by palpating the fundal
section of the uterus using the fingertips. Many women may experience labor pain in the
lower segment of the uterus that may be unrelated to the firmness of the contraction
detectable in the uterine fundus. The frequency of uterine contractions is determined by
palpating from the beginning of one contraction to the beginning of the next contraction.
Assessment of uterine activity is performed in intervals based on the stage of labor. As
labor progresses this assessment is performed more frequently.
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