Chapter 8 - Test Questions

Leifer: Introduction to Maternity & Pediatric Nursing, 6th Edition Chapter 08: Nursing Care of Women with Complications During Labor and Birth Test Bank MULTIPLE CHOICE 1. a. b. c. d.

Following an amniotomy, the nursing assessment that should be reported immediately is: fetal heart rate is regular at 154 beats/min. amniotic fluid is clear with flecks of vernix. amniotic fluid is watery and pale green. maternal temperature is 37.8° C.

ANS: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise. DIF: TOP: KEY: MSC:

Cognitive Level: Analysis REF: p. 175 Obstetric Procedures—Amniotomy Nursing Process Step: Implementation NCLEX: Physiological Integrity

OBJ: 3

2. A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurse’s initial action should be to: a. stop the oxytocin infusion. b. continue the infusion and report the findings to the physician. c. turn her on her left side and reassess the contractions. d. administer oxygen by mask. ANS: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur. DIF: TOP: KEY: MSC:

Cognitive Level: Analysis REF: p. 177 Obstetric Procedures—Induction of Labor Nursing Process Step: Implementation NCLEX: Physiological Integrity

OBJ: 3

3. The nursing care of a woman with a third-degree laceration immediately after delivery would include: a. warm compresses to the perineum. b. cold pack to the perineum. c. warm sitz bath. d. elevation of hips to prevent edema. ANS: B Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

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Ice is applied to the perineum to reduce bruising and edema. DIF: Cognitive Level: Application REF: p. 181 OBJ: 3 TOP: Obstetric Procedures—Lacerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. After several hours of labor, a nursing assessment reveals that a woman’s cervix is 5 cm dilated but contractions are becoming shorter and less frequent. The nurse knows that this labor pattern is described as: a. normal. b. hypotonic. c. hypertonic. d. false. ANS: B The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase. DIF: OBJ: KEY: MSC:

Cognitive Level: Comprehension REF: p. 186, Box 8-1 5 TOP: Abnormal Labor Nursing Process Step: Assessment NCLEX: Physiological Integrity: Physiological Adaptation

5. When a labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will: a. perform an amniotomy. b. initiate tocolytic drugs. c. order a sedative for the patient. d. plan to do an emergency cesarean section. ANS: A Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact. DIF: Cognitive Level: Comprehension TOP: Abnormal Labor MSC: NCLEX: Physiological Integrity 6. a. b. c. d.

REF: p. 186 OBJ: 5 KEY: Nursing Process Step: Implementation

The nurse would assess an infant delivered with the use of forceps for: loss of hair from contact with forceps. sacral hematoma. facial asymmetry. shoulder dislocation.

ANS: C

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Pressure from forceps may injure the infant’s facial nerve, which is evidenced by facial asymmetry. DIF: Cognitive Level: Analysis REF: p. 181 OBJ: 3 TOP: Obstetric Procedures—Forceps Delivery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. A new mother is distressed and tearful about the elevated dome over her infant’s posterior fontanelle. The nurse’s best response is, “This condition will resolve itself in a few days. It is caused by: a. prolonged pressure against the partially dilated cervix.” b. small leak of fluid through the posterior fontanelle.” c. pressure of the forceps during delivery.” d. the effect of the vacuum extractor.” ANS: D The “chignon” is due to the effect of the vacuum extractor and will disappear in a few days. DIF: Cognitive Level: Comprehension REF: p. 180 OBJ: 2 TOP: Chignon KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The frustrated patient in labor that has been affected by decreased uterine muscle tone complains, “My doctor won’t induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need?” The nurse is aware that prior to induction, the patient should have a Bishop score of at least: a. 6. b. 8. c. 10. d. 12. ANS: A The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG). DIF: OBJ: KEY: MSC:

Cognitive Level: Comprehension REF: p. 175, Table 8-1 2 TOP: Bishop Scoring for Vaginal Delivery Nursing Process Step: Implementation NCLEX: Physiological Integrity: Reduction of Risk

9. A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). To encourage fetal rotation and pain relief the nurse would position the patient:

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Test Bank a. b. c. d.

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prone with legs supported and give her a back massage. supine with legs bent at the knee. standing with support. sitting up and leaning forward on the over-bed table.

ANS: D A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support. DIF: Cognitive Level: Comprehension REF: p. 189 OBJ: 6 TOP: Abnormal Labor KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 10. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman asks the nurse, “Please give me something.” The most appropriate pain relief intervention for a woman in precipitate labor is to: a. get an order for an intravenous narcotic. b. notify the anesthesiologist for an epidural block. c. stay and breathe with her during contractions. d. tell her to bear with it because she is close to delivery. ANS: C The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction. DIF: Cognitive Level: Application REF: p. 192 OBJ: 6 TOP: Abnormal Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. She must be closely observed for signs of: a. chorioamnionitis. b. hemorrhage. c. hypotension. d. amniotic fluid embolism. ANS: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. DIF: Cognitive Level: Analysis REF: p. 192 OBJ: 5 TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk

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12. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia ANS: A Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol. DIF: Cognitive Level: Analysis REF: p. 193 OBJ: 6 TOP: Preterm Labor KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. The statement that indicates a woman understands activity limitations for the management of preterm labor is: a. “After my shower in the morning, I do the laundry and straighten up the house, then I rest.” b. “I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.” c. “I have a 2-year-old to care for, but I try to rest as much as I can.” d. “I get really bored at home, so I go to the shopping mall for just a little while.” ANS: B Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest. DIF: Cognitive Level: Application REF: pp. 193-194 OBJ: 5 TOP: Preterm Labor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. A student nurse questions the instructor as to what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. The best response is that the fundus of a patient with a cesarean section is: a. not assessed until the second postoperative day. b. assessed by “walking” fingers from side of uterus to the midline. c. assessed only if large clots appear in lochia. d. only once every shift. ANS: B Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. DIF:

Cognitive Level: Analysis

REF: p. 183

OBJ: 6

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TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. A pulsating structure is felt during a vaginal examination of a woman in labor. To prevent compression of a prolapsed cord, the nurse would position the woman: a. on her right side with knees flexed. b. on her left side with a pillow placed between her legs. c. on her back with her head lower than the rest of her body. d. supine with her legs elevated and bent at the knee. ANS: C The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. DIF: TOP: KEY: MSC:

Cognitive Level: Application REF: p. 195 OBJ: 6 Emergencies During Childbirth—Prolapsed Umbilical Cord Nursing Process Step: Implementation NCLEX: Physiological Integrity: Reduction of Risk

16. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, “My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section.” The most appropriate nursing diagnosis is: a. anxiety related to the development of postpartum complications. b. ineffective individual coping related to unfamiliarity with procedures. c. risk for ineffective parenting related to emergency cesarean section. d. grieving related to loss of expected birth experience. ANS: D Women who have cesarean birth usually need greater support than those having vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur. DIF: Cognitive Level: Application REF: p. 183 OBJ: 3 TOP: Cesarean Section KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. A pregnant woman’s membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. The nurse planning discharge instructions would teach the woman to: a. report any increase in fetal activity. b. notify her obstetrician for a temperature above 37.8 C (100 F). c. massage her breasts to promote uterine relaxation. d. rest in a side-lying Trendelenburg position with hips elevated. ANS: B

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For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). DIF: Cognitive Level: Application REF: p. 191 OBJ: 6 TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. A woman who is 24 weeks’ pregnant is placed on an intravenous infusion of magnesium sulfate. The nurse should inform the patient that she might experience what side effect? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency ANS: C Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug. DIF: Cognitive Level: Knowledge TOP: Preterm Labor MSC: NCLEX: Physiological Integrity

REF: p. 193 OBJ: 6 KEY: Nursing Process Step: Implementation

19. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. The nurse is aware that anxiety can affect labor by: a. decreasing a woman’s pain sensitivity. b. reducing blood flow to the uterus. c. increasing the ability to tolerate pain. d. enhancing maternal pushing through greater muscle tension. ANS: B Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. DIF: Cognitive Level: Comprehension REF: p. 191 OBJ: 2 TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. The nurse should: a. give the pain remedy. b. notify the charge nurse immediately. c. turn patient to her back and flex her knees. d. suggest that the coach give her a back rub.

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ANS: B Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately. DIF: Cognitive Level: Analysis REF: p. 195 OBJ: 3 TOP: Uterine Rupture KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. The nurse explains that a “cervical ripening” softens the cervix with the use of: a. prostaglandin gel insertion. b. intravenous oxytocin. c. warm saline douches. d. nipple stimulation. ANS: A Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours being monitored for uterine contractions. DIF: Cognitive Level: Comprehension REF: p. 176 OBJ: 3 TOP: Cervical Ripening KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 22. The nurse explains to the patient who is threatening preterm labor that glucocorticoids are given prior to delivery in order to: a. prevent infection. b. increase fetal lung maturity. c. increase blood flow from placenta. d. relax the cervix. ANS: B Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. DIF: Cognitive Level: Comprehension REF: p. 193 OBJ: 4 TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 23. After an amniotomy, the nurse should be alert for what sign(s) of infection? Select all that apply. a. Oral temperature of 37 C (99.8 F) b. Increase of fetal heart rate from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain

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e. Edematous labia ANS: B Increase in the FHR above 160 beats/minute frequently precedes a woman’s temperature elevation. All the other options are normal findings for late pregnancy. DIF: Cognitive Level: Analysis REF: p. 176 OBJ: 2 TOP: Postamniotomy Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. What is(are) the rationales for labor induction? Select all that apply. a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency ANS: D, E Maternal diabetes and placental insufficiency are rationales for induction. Options a, b, and c are contraindications for labor induction. DIF: Cognitive Level: Analysis REF: p. 175 OBJ: 2 TOP: Rationales for Labor Induction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 25. Which intervention(s) could a nurse apply to help stimulate contractions? Select all that apply. a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration ANS: A, B, C Sitting upright, ambulating, and stimulation of the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient, but do not stimulate more effective labor. DIF: Cognitive Level: Analysis REF: p. 177 OBJ: 2 TOP: Hypotonic Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. What complication(s) of overstimulation of uterine contractions may occur? Select all that apply. a. Water intoxication

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Test Bank b. c. d. e.

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Impaired placental exchange of oxygen and nutrients Increased blood pressure Convulsions Uterine rupture

ANS: A, B, E The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. DIF: Cognitive Level: Application REF: p. 174 OBJ: 3 TOP: Complication of Oxytocin KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. To increase the quality of uterine contractions, the nurse instructs the patient to do what to stimulate her nipples? Select all that apply. a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Press the palms of hands down on her breasts. ANS: B, C, D Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. DIF: Cognitive Level: Application REF: p. 175 OBJ: 5 TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 28. Following an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. ANS: amnioinfusion A warm saline bolus is instilled in the uterus to "float" the fetus to relieve pressure on the cord. DIF: Cognitive Level: Knowledge REF: p. 176 TOP: Amnioinfusion KEY: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: 3 Nursing Process Step:

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29. The nurse explains to a patient that a minimum score of _____ on the Bishop scale is predictive of successful labor induction. ANS: 6 Refer to the Bishop Scale, Table 8-1 DIF: Cognitive Level: Application REF: p. 177 OBJ: 3 TOP: Bishop Scoring System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 30. A(n) _______________ is a narrow cone inserted into the cervix to “ripen” the cervix to increase uterine contractions. ANS: laminaria A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water. DIF: Cognitive Level: Comprehension REF: p. 176 OBJ: 3 TOP: Laminaria KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

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