Family Nursing Care During Labor & Birth: Understanding True Labor & Assessment Techniques, Exams of Nursing

Download Family Nursing Care During Labor & Birth: Understanding True Labor & Assessment Techniques and more Exams Nursing in PDF only on Docsity! Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 1. 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. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 2. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's 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. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 5. 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 Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 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. 6. When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: a. dilation of the cervix. b. descent of the fetus. c. rupture of the amniotic membranes. d. increase in bloody show. - Correct Answer ANS: A The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor. Descent of the fetus, or engagement, may occur before labor. Rupture of membranes may occur with or without the presence of labor. Bloody show may indicate Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition slow, progressive cervical change (e.g., effacement) in both true and false labor. 7. The nurse who performs vaginal examinations to assess a woman's progress in labor should: a. perform an examination at least once every hour during the active phase of labor. b. perform the examination with the woman in the supine position. c. wear two clean gloves for each examination. d. discuss the findings with the woman and her partner. - Correct Answer ANS: D The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned to avoid supine hypotension. The examiner should wear a Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor 10. The nurse knows that the second stage of labor, the descent phase, has begun when: a. the amniotic membranes rupture. b. the cervix cannot be felt during a vaginal examination. c. the woman experiences a strong urge to bear down. d. the presenting part is below the ischial spines. - Correct Answer ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 11. When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: a. encouraging the woman to try various upright positions, including squatting and standing. b. telling the woman to start pushing as soon as her cervix is fully dilated. c. continuing an epidural anesthetic so pain is reduced and the woman can relax. d. coaching the woman to use sustained, 10- to 15-second, closed- glottis bearing-down efforts with each contraction. - Correct Answer ANS: A Upright positions and squatting both may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if the woman is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia. 12. Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: a. first stage, latent phase. b. first stage, active phase. c. first stage, transition phase. d. second stage, latent phase. - Correct Answer ANS: B Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition a. the placenta has separated. b. a cervical tear occurred during the birth. c. the woman is beginning to hemorrhage. d. clots have formed in the upper uterine segment. - Correct Answer ANS: A Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 15. The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. relieve pain. b. stimulate uterine contraction. c. prevent infection. d. facilitate rest and relaxation. - Correct Answer ANS: B Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain or prevent infection. They cause the uterus to contract, which reduces blood loss. Oxytocics do not facilitate rest and relaxatio 16. After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to: a. facilitate maternal-newborn interaction. b. stimulate the uterus to contract. c. prevent neonatal hypoglycemia. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition d. initiate the lactation cycle. - Correct Answer ANS: B Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin, which prevents hemorrhage. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth. 17. A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that "true" labor contractions: a. increase with activity such as ambulation. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition d. formulation of the woman's plan of care for labor. - Correct Answer ANS: D Labor care begins when progressive, regular contractions begin; the blood-tinged mucoid vaginal discharge appears; or fluid is discharged from the vagina. The woman and nurse can formulate their plan of care before labor or during treatment. 20. Nurses can help their patients by keeping them informed about the distinctive stages of labor. Which description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours - Correct Answer ANS: B Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate, irregular contractions; dilation up to 3 cm; brownish-to-pale pink mucus, and a duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8- to 10- cm dilation; and a duration of 20 to 40 minutes. 21. It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care? a. The patient is not considered to be in true labor (according to the Emergency Medical Treatment and Active Labor Act [EMTALA]) until a qualified health care provider says she is. b. The woman can have only her male partner or predesignated "doula" with her at assessment. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition c. The patient's weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth. d. The nurse may exchange information about the patient with family members. - Correct Answer ANS: C According to EMTALA, a woman is entitled to active labor care and is presumed to be in "true" labor until a qualified health care provider certifies otherwise. A woman can have anyone she wishes present for her support. The risk for CPD is especially great for petite women or those who have gained 16 kg or more. All patients should have their weight and BMI calculated on admission. This is part of standard nursing care on a maternity unit and not a regulatory concern. According to the Health Insurance Portability and Accountability Act (HIPAA), the patient must give consent for others to receive any information related to her condition. 22. Leopold maneuvers would be an inappropriate method of assessment to determine: Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition mother's umbilicus. In a breech position it is heard above the mother's umbilicus. 25. With regard to a woman's intake and output during labor, nurses should be aware that: a. the tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. c. routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. when a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly. - Correct Answer ANS: A Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition Routine use of an enema is at best ineffective and may be harmful. A multiparous woman may feel the urge to defecate and it may mean birth will follow quickly, but not for a first timer. 26. If a woman complains of back labor pain, the nurse could best suggest that she: a. lie on her back for a while with her knees bent. b. do less walking around. c. take some deep, cleansing breaths. d. lean over a birth ball with her knees on the floor. - Correct Answer ANS: D The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 27. Which description of the phases of the second stage of labor is accurate? a. Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied d. Transitional phase: Woman "laboring down," fetal station 0, duration 15 minutes - Correct Answer ANS: C The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or "laboring down," period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician. - Correct Answer ANS: D Reddish-haired women have tissue that is less distensible than that of darker-skinned women and therefore may have less efficient healing. First time mothers are also more at risk, especially with breech births, long second-stage labors, or rapid labors in which there is insufficient time for the perineum to stretch. The rate of episiotomies is higher when obstetricians rather than midwives attend births. 31. Concerning the third stage of labor, nurses should be aware that: a. the placenta eventually detaches itself from a flaccid uterus. b. an expectant or active approach to managing this stage of labor reduces the risk of complications. c. it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. d. the major risk for women during the third stage is a rapid heart rate. - Correct Answer ANS: B Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition Active management facilitates placental separation and expulsion, thus reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is after birth hemorrhage. 32. For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the patient to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the patient view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing carea. Telling the patient to relax and that it won't hurt much. b. Limiting the number of procedures that invade her body. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition c. Reassuring the patient that as the nurse you know what is best. d. Allowing unlimited care providers to be with the patient. - Correct Answer ANS: B The number of invasive procedures such as vaginal examinations, internal monitoring, and intravenous therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the patient's recalling the phrases of her abuser (e.g., "Relax, this won't hurt" or "Just open your legs.") The woman's sense of control should be maintained at all times. The nurse should explain procedures at the patient's pace and wait for permission to proceed. Protecting the patient's environment by providing privacy and limiting the number of staff who observe the patient will help to make her feel safe. 33. As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition 35. The primary difference between the labor of a nullipara and that of a multipara is the: a. amount of cervical dilation. b. total duration of labor. c. level of pain experienced. d. sequence of labor mechanisms. - Correct Answer ANS: B Multiparas usually labor more quickly than nulliparas, thus making the total duration of their labor shorter. Cervical dilation is the same for all labors. The level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms remains the same with all labors. 36. A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are: a. contraction pattern, amount of discomfort, and pregnancy history. Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition b. fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. identification of ruptured membranes, the woman's gravida and para, and her support person. d. last food intake, when labor began, and cultural practices the couple desires. - Correct Answer ANS: B All options describe relevant intrapartum nursing assessments; however, this focused assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. This includes: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices. 37. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. admitted and prepared for a cesarean birth. b. admitted for extended observation. c. discharged home with a sedative. d. discharged home to await the onset of true labor. - Correct Answer ANS: D This situation describes a woman with normal assessments who is probably in false labor and will likely not deliver rapidly once true labor begins. There is no indication that further assessments or observations are indicated; therefore, the patient will be discharged along with instructions to return when contractions increase in intensity and frequency. Neither a cesarean birth nor a sedative is required at this time. 38. A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to: Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition b. 8 c. 9 d. 10 - Correct Answer ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. 41. The nurse thoroughly dries the infant immediately after birth primarily to: a. stimulate crying and lung expansion. b. remove maternal blood from the skin surface. c. reduce heat loss from evaporation. d. increase blood supply to the hands and feet. - Correct Answer ANS: C Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition infant is to prevent heat loss. Rubbing the infant does stimulate crying; however, it is not the main reason for drying the infant. This process does not remove all the maternal blood.