Deck 56: The Birth Process

Question 1

The nurse encourages the labor client to void at least every 2 hours,primarily because a distended bladder may:

A)cause severe pain
B)impede fetal descent
C)result in bladder trauma during the birth process
D)result in kidney infection from stasis of urine

Answer 1

impede fetal descent

Question 2

Which of these designations accurately describes the fetal position during delivery when its face is directed toward the health care provider's left hand and the mother's sacrum?

A)LOA (left occiput anterior)
B)LOP (left occiput posterior)
C)ROA (right occiput anterior)
D)ROP (right occiput posterior)

Answer 2

LOA (left occiput anterior)

Question 3

Shortly after the client's health care provider evaluated her cervical dilation as being 7 centimeters,she tells you,"I think I'm about to have the baby!" Which of these actions should the nurse take immediately?

A)Instruct her to pant.
B)Leave the room to notify the health care provider.
C)Open an emergency birth pack.
D)Visualize her perineum for crowning.

Answer 3

Visualize her perineum for crowning.

Question 4

A labor client who is 8 centimeters dilated suddenly starts to shake her arms and legs,and then vomits.She says,"I can't take it! Give me something for the pain!" What action should the nurse take?

A)Explain that these reactions are normal during the transition phase.
B)Give her an analgesic,and review relaxation and breathing techniques with her.
C)Notify her health care provider.
D)Take her vital signs.

Question 5

What is the significance of crowning?

A)Birth is imminent.
B)Labor must be induced within 12 to 24 hours.
C)The placenta has separated from the wall of the uterus.
D)The recovery stage of labor begins.

Question 6

A client comes to the hospital at 38 weeks' gestation thinking she is in labor,but after several hours of observation she is sent home.The client asks how she can tell the difference between true labor and false labor.Which of the following should the nurse indicate will occur in true labor?

A)a sudden burst of energy
B)an increase in bloody show
C)more discomfort with the uterine contractions
D)contractions increase in intensity and duration

Question 7

The client asks the nurse,"When does the first stage of labor end?" The MOST appropriate response by the nurse would be when the:

A)cervical dilation is 4 centimeters
B)cervical dilation is 10 centimeters
C)crowning occurs
D)uterine contractions occur every 5 to 7 minutes

Question 8

When are labor clients urged to bear down?

A)between each contraction as soon as the cervix is completely effaced
B)between each contraction as soon as the membranes have ruptured
C)with each contraction as soon as engagement has occurred
D)with each contraction as soon as the cervix is completely dilated

Question 9

Which client position is preferred during the active and transition phases of labor because it promotes uteroplacental blood flow?

A)semi-Fowler's
B)side-lying
C)supine
D)walking

Question 10

The nurse is aware that the maternal passage of primary concern when a client is planning a vaginal birth would be:

A)cervix
B)true pelvis
C)uterus
D)vagina

Question 11

In describing the intensity of uterine contractions,the nurse uses the term moderate if the fundus feels like what body part?

A)chin
B)forehead
C)nose
D)thigh

Question 12

What is the immediate concern when a client's membranes rupture spontaneously prior to fetal engagement?

A)a "dry" and painful birth
B)development of a fetal infection
C)development of a vaginal infection
D)prolapsed umbilical cord

Question 13

The laboring client is experiencing a vertex presentation.The nurse would expect the normal presenting part to be the:

A)brow
B)mentum
C)occiput
D)sacrum

Question 14

When a fetus presenting as a breech has both legs extended so that the feet are near the face,the nurse would expect to find which type of breech?

A)complete
B)footling
C)frank
D)kneeling

Question 15

To what does the term fetal presentation refer?

A)the part of the fetus that enters the pelvis first
B)relationship of the fetal body parts to one another
C)relationship of the landmark on the presenting part to the four quadrants of the mother's pelvis
D)relationship of the fetus's long axis to the mother's long axis

Question 16

Immediately after the rupture of membranes (either spontaneously or artificially),it is most important for the nurse to:

A)assess the fetal heart rate (FHR)for a full minute,and report significant changes
B)change the linen savers under the client's hip
C)note the color,quantity,and odor,and document on the chart
D)perform a vaginal examination to check for a prolapsed umbilical cord

Question 17

The nurse should take the blood pressure of a client in labor between contractions,because during a contraction the client's:

A)blood pressure increases
B)blood pressure is erratic
C)concentration is disrupted
D)cooperation is unpredictable

Question 18

The nurse monitors the frequency of contractions timed:

A)from the beginning of one contraction to the beginning of the next
B)from the beginning of one contraction to the end of the next
C)from the end of one contraction to the beginning of the next
D)from the end of one contraction to the end of the next

Question 19

A gravida II para I client who is at 40 weeks' gestation states,"I don't think I'm ready for labor.Last time,I experienced 'lightening' 2 weeks before now." Which of these responses should the nurse make?

A)"Lightening is an unpredictable sign of impending labor."
B)"Lightening may not occur in a multigravida until labor has started."
C)"You may be correct.It always occurs about 2 weeks before labor begins."
D)"You must have miscalculated your due date."

Question 20

A primigravida is admitted in labor at 3 centimeters dilation.She asks the nurse,"How long will my labor last?" The nurse's response should indicate that the average length is approximately how many hours?

A)3 to 5
B)8 to 10
C)13 to 15
D)17 to 19

Question 21

When a prolapsed cord is identified,which of these nursing actions assumes priority?

A)Assist client into a knee-chest position or modified Sims' position.
B)Attempt to replace the cord into the uterus with a sterile gloved hand.
C)Cover the cord with a sterile towel,and start oxygen via mask at 10 L per minute.
D)Insert two fingers of a sterile gloved hand into the vagina,and put pressure on the presenting part to lift it off the cord.

Question 22

Flexion of the fetal head,a fetal mechanism of labor,assists it to move through the maternal pelvis by:

A)allowing the narrowest part of the skull to enter the pelvic outlet
B)causing lightening
C)facilitating engagement
D)shortening the entire birth process

Question 23

Which of these regional blocks provides rapid pain relief of short duration without hypotension or motor impairment for women in labor?

A)epidural
B)intrathecal
C)local infiltration
D)pudendal

Question 24

In addition to monitoring vital signs,the nursing care priority during the fourth stage of labor is to:

A)allow the mother to bond with her infant and begin breastfeeding
B)assess uterine tone and the amount of vaginal bleeding
C)assist the mother to void or catheterize her
D)keep an ice pack on the perineum or episiotomy

Question 25

The nurse is aware that induction of labor is considered for which of the following situations? (Select all that apply. )

A)PROM has occurred.
B)Gestational hypertension is present.
C)Maternal diabetes is present.
D)A desired date of delivery is needed.
E)Vaginal infection is present.

Question 26

When caring for a client receiving a secondary oxytocin infusion to induce or augment labor,the nurse would NOT discontinue the oxytocin in which of these situations?

A)when contractions occur every 2 minutes
B)when the fetal monitor shows no variability
C)when the contractions are of 40 to 60 seconds' duration
D)when the fetal monitor shows prolonged decelerations

Question 27

Placing the labor client in the hands-and-knees position seems to facilitate which of these?

A)pain relief during the transition phase of labor
B)fetal rotation from an occiput posterior position to an anterior position
C)fetal progression through the pelvis
D)uteroplacental blood flow

Question 28

Which of these is considered to be a danger sign that may occur during labor?

A)fetal heart rate between 120 and 160 bpm with no late or variable decelerations
B)maternal temperature above 100.4 degrees Fahrenheit
C)contractions lasting longer than 90 seconds
D)flecks of vernix in amniotic fluid

Question 29

A client in the active phase of labor develops hypotonic uterine contractions.In evaluating and treating her,the health care provider will usually prescribe:

A)an ultrasound
B)bed rest and analgesics
C)antibiotics
D)cesarean delivery

Question 30

As the head of the fetus approaches delivery and the phrase "station plus one" is used,in which position is the head in relation to the ischial spines?

A)1 centimeter above
B)1 centimeter below
C)1 fingerbreadth above
D)1 fingerbreadth below

Question 31

While awaiting the health care provider's arrival in a precipitate birth,which of these actions should the nurse take first?

A)Hold the fetal head back by telling the mother to keep her legs together.
B)Dry the baby immediately.
C)Check for presence of a nuchal cord.
D)Suction the baby's nose.

Question 32

When an emergency cesarean birth is necessary,it is MOST important for the nurse to:

A)review with the client the events that necessitated this type of delivery
B)tell the client this is a safer method of delivery for her and the baby
C)allow the client to grieve for not being able to have a normal delivery
D)give the client a chance to rest before the procedure begins

Question 33

In which of these situations is a forceps-assisted birth indicated?

A)for a fetal vertex presentation
B)when cephalopelvic disproportion is present
C)for a mother with a history of heart disease
D)for a fetal prolapsed umbilical cord

Question 34

The nurse assesses a newborn infant at 1 and 5 minutes using the APGAR score.If the 1-minute score is between 4 and 8,which action should the nurse take?

A)Administer Narcan to counteract the narcotic the mother received during labor.
B)Begin resuscitation immediately.
C)Gently rub the infant's back and administer oxygen.
D)Proceed with normal newborn care because no special interventions are required.

Question 35

Clients in labor are encouraged to walk in which of these circumstances?

A)when the membranes are intact
B)after pain medication has been given
C)when crowning has occurred
D)before the presenting part is engaged

Question 36

Ten minutes after the cutting of the baby's umbilical cord,the nurse observes a sudden gush of blood,a lengthening of the cord at the vaginal orifice,and that the uterus has assumed a more globular shape.These signs are MOST indicative of:

A)hemorrhage due to uterine atony
B)inversion of the uterus
C)multiple birth
D)placental separation

Question 37

When assisting a labor client with her breathing techniques,the nurse knows the client will use which of these breathing methods during the transition phase of labor?

A)breath holding and pushing
B)shallow
C)slow,deep chest
D)pant-blow

Question 38

Shortly after delivery a client experiences a shaking chill.What is the nurse's MOST appropriate action?

A)Cover her with a warmed blanket.
B)Notify her health care provider of this development.
C)Obtain a culture of her lochia.
D)Take her temperature.