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Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 8th Edition
MULTIPLE CHOICE
1. What does the nurse note when measuring the frequency of a laboring woman’s contractions?
a. How long the patient states the contractions last
b. The time between the end of one contraction and the beginning of the next
c. The time between the beginning and the end of one contraction
d. The time between the beginning of one contraction and the beginning of the next
ANS: D
The frequency of contractions is the elapsed time from the beginning of one contraction to the
beginning of the next contraction.
DIF: Cognitive Level: Comprehension REF: p. 127 OBJ: 3
TOP: Frequency of Contractions KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Why is the relaxation phase between contractions important?
a. The laboring woman needs to rest.
b. The uterine muscles fatigue without relaxation.
c. The contractions can interfere with fetal oxygenation.
d. The infant progresses toward delivery at these times.
ANS: C
Blood flow from the m ot h eTr Ei nSt oT tBhA
eNplK
acSeE
ntL
a LgrEa R
d u.aC
llyO dMecreases during contractions. During
the interval between contractions, the placenta refills with oxygenated blood for the fetus.
DIF: Cognitive Level: Comprehension REF: p. 127 OBJ: 3
TOP: Interval KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What contraction duration and interval does the nurse recognize could result in fetal
compromise?
a. Duration shorter than 30 seconds, interval longer than 75 seconds
b. Duration shorter than 90 seconds, interval longer than 120 seconds
c. Duration longer than 90 seconds, interval shorter than 60 seconds
d. Duration longer than 60 seconds, interval shorter than 90 seconds
ANS: C
Persistent contraction durations longer than 90 seconds or contraction intervals less than 60
seconds may reduce fetal oxygen supply.
DIF: Cognitive Level: Comprehension REF: p. 127|Safety Alert
OBJ: 4 TOP: Contraction/Fetal Compromise
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. Vaginal examination reveals the presenting part is the infant’s head, which is well flexed on
the chest. What is this presentation?
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a. Vertex
b. Military
c. Brow
d. Face
ANS: A
In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the
chest.
DIF: Cognitive Level: Comprehension REF: p. 129 OBJ: 3
TOP: Fetal Position KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. What does meconium-stained amniotic fluid indicate when the infant is in a vertex
presentation?
a. Fetal distress
b. Fetal maturity
c. Intact gastrointestinal tract
d. Dehydration in the mother
ANS: A
Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is
an indicator of fetal compromise.
DIF: Cognitive Level: Comprehension REF: p. 144 OBJ: 4
TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus’s hips
are flexed and the knees are extended. How would the nurse record this presentation?
a. Complete breech
b. Frank breech
c. Double footling
d. Buttocks presentation
ANS: B
When a fetus presents in a frank breech position, the legs are flexed at the hips and extend
toward the shoulders.
DIF: Cognitive Level: Application REF: p. 129|Figure 6-7
OBJ: 3 | 4 TOP: Components of the Birth Process
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The
nurse knows that what indicates the beginning of true labor?
a. Contractions that are relieved by walking
b. Discomfort in the abdomen and groin
c. A decrease in vaginal discharge
d. Regular contractions becoming more frequent and intense
ANS: D
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In true labor, contractions gradually develop a regular pattern and become more frequent,
longer, and more intense.
DIF: Cognitive Level: Application REF: p. 134|p. 137
OBJ: 6 TOP: Initiation of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse
when she should go to the hospital. What is the nurse’s most informative response?
a. “When you feel increased fetal movement”
b. “When contractions are 10 minutes apart”
c. “When membranes have ruptured”
d. “When abdominal or groin discomfort occurs”
ANS: C
Ruptured membranes are an indication that the woman should go to the hospital or birthing
center.
DIF: Cognitive Level: Application REF: p. 134|p. 137
OBJ: 5 TOP: Admission to the Hospital or Birth Center
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the
patient about contractions during this stage of labor?
a. They get the infant positioned for delivery.
b. They push the infant inTtoEtS
heTvBaA
giNnK
a.SELLER.COM
c. They dilate and efface the cervix.
d. They get the mother prepared for true labor.
ANS: C
The first stage of labor describes the time from the onset of labor until full dilation of the
cervix.
DIF: Cognitive Level: Comprehension REF: p. 155|Table 6-6
OBJ: 5 TOP: First Stage of Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing
at her birthing coach and the nurse, what does the nurse assess as the most likely explanation
for the woman’s change in behavior?
a. Labor has progressed to the transition phase.
b. She lacked adequate preparation for the labor experience.
c. The woman would benefit from a different form of analgesia.
d. The contractions have increased from mild to moderate intensity.
ANS: A
If a woman suddenly loses control and becomes irritable, suspect that she has progressed to
the transition stage of labor.
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DIF: Cognitive Level: Analysis REF: p. 155|Table 6-6
OBJ: 5 TOP: Transition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. What is the function of contractions during the second stage of labor?
a. Align the infant into the proper position for delivery
b. Dilate and efface the cervix
c. Push the infant out of the mother’s body
d. Separate the placenta from the uterine wall
ANS: C
The contractions push the infant out of the mother’s body as the second stage of labor ends
with the birth of the infant.
DIF: Cognitive Level: Knowledge REF: p. 155|Table 6-6
OBJ: 5 TOP: Second Stage of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. What marks the end of the third stage of labor?
a. Full cervical dilation
b. Expulsion of the placenta and membranes
c. Birth of the infant
d. Engagement of the head
ANS: B
The third stage of labor extends from the birth of the infant until the placenta is detached and
expelled. TESTBANKSELLER.COM
DIF: Cognitive Level: Knowledge REF: p. 155|Table 6-6
OBJ: 5 TOP: Third Stage of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. Why should the nurse encourage the mother to void during the fourth stage of labor?
a. A full bladder could interfere with cervical dilation.
b. A full bladder could obstruct progress of the infant through the birth canal.
c. A full bladder could obstruct the passage of the placenta.
d. A full bladder could predispose the mother to uterine hemorrhage.
ANS: D
A full bladder immediately after birth can cause excessive bleeding because it pushes the
uterus upward and interferes with contractions.
DIF: Cognitive Level: Comprehension REF: p. 155|Table 6-6
OBJ: 5 TOP: Nursing Care Immediately After Birth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14. The nurse observes the patient bearing down with contractions and crying out, “The baby is
coming!” What is the best nursing intervention?
a. Find the physician.
TESTBANKSELLER.COM
Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 8th Edition
MULTIPLE CHOICE
1. What does the nurse note when measuring the frequency of a laboring woman’s contractions?
a. How long the patient states the contractions last
b. The time between the end of one contraction and the beginning of the next
c. The time between the beginning and the end of one contraction
d. The time between the beginning of one contraction and the beginning of the next
ANS: D
The frequency of contractions is the elapsed time from the beginning of one contraction to the
beginning of the next contraction.
DIF: Cognitive Level: Comprehension REF: p. 127 OBJ: 3
TOP: Frequency of Contractions KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Why is the relaxation phase between contractions important?
a. The laboring woman needs to rest.
b. The uterine muscles fatigue without relaxation.
c. The contractions can interfere with fetal oxygenation.
d. The infant progresses toward delivery at these times.
ANS: C
Blood flow from the m ot h eTr Ei nSt oT tBhA
eNplK
acSeE
ntL
a LgrEa R
d u.aC
llyO dMecreases during contractions. During
the interval between contractions, the placenta refills with oxygenated blood for the fetus.
DIF: Cognitive Level: Comprehension REF: p. 127 OBJ: 3
TOP: Interval KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What contraction duration and interval does the nurse recognize could result in fetal
compromise?
a. Duration shorter than 30 seconds, interval longer than 75 seconds
b. Duration shorter than 90 seconds, interval longer than 120 seconds
c. Duration longer than 90 seconds, interval shorter than 60 seconds
d. Duration longer than 60 seconds, interval shorter than 90 seconds
ANS: C
Persistent contraction durations longer than 90 seconds or contraction intervals less than 60
seconds may reduce fetal oxygen supply.
DIF: Cognitive Level: Comprehension REF: p. 127|Safety Alert
OBJ: 4 TOP: Contraction/Fetal Compromise
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. Vaginal examination reveals the presenting part is the infant’s head, which is well flexed on
the chest. What is this presentation?
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a. Vertex
b. Military
c. Brow
d. Face
ANS: A
In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the
chest.
DIF: Cognitive Level: Comprehension REF: p. 129 OBJ: 3
TOP: Fetal Position KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. What does meconium-stained amniotic fluid indicate when the infant is in a vertex
presentation?
a. Fetal distress
b. Fetal maturity
c. Intact gastrointestinal tract
d. Dehydration in the mother
ANS: A
Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is
an indicator of fetal compromise.
DIF: Cognitive Level: Comprehension REF: p. 144 OBJ: 4
TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
TESTBANKSELLER.COM
6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus’s hips
are flexed and the knees are extended. How would the nurse record this presentation?
a. Complete breech
b. Frank breech
c. Double footling
d. Buttocks presentation
ANS: B
When a fetus presents in a frank breech position, the legs are flexed at the hips and extend
toward the shoulders.
DIF: Cognitive Level: Application REF: p. 129|Figure 6-7
OBJ: 3 | 4 TOP: Components of the Birth Process
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The
nurse knows that what indicates the beginning of true labor?
a. Contractions that are relieved by walking
b. Discomfort in the abdomen and groin
c. A decrease in vaginal discharge
d. Regular contractions becoming more frequent and intense
ANS: D
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In true labor, contractions gradually develop a regular pattern and become more frequent,
longer, and more intense.
DIF: Cognitive Level: Application REF: p. 134|p. 137
OBJ: 6 TOP: Initiation of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse
when she should go to the hospital. What is the nurse’s most informative response?
a. “When you feel increased fetal movement”
b. “When contractions are 10 minutes apart”
c. “When membranes have ruptured”
d. “When abdominal or groin discomfort occurs”
ANS: C
Ruptured membranes are an indication that the woman should go to the hospital or birthing
center.
DIF: Cognitive Level: Application REF: p. 134|p. 137
OBJ: 5 TOP: Admission to the Hospital or Birth Center
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the
patient about contractions during this stage of labor?
a. They get the infant positioned for delivery.
b. They push the infant inTtoEtS
heTvBaA
giNnK
a.SELLER.COM
c. They dilate and efface the cervix.
d. They get the mother prepared for true labor.
ANS: C
The first stage of labor describes the time from the onset of labor until full dilation of the
cervix.
DIF: Cognitive Level: Comprehension REF: p. 155|Table 6-6
OBJ: 5 TOP: First Stage of Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing
at her birthing coach and the nurse, what does the nurse assess as the most likely explanation
for the woman’s change in behavior?
a. Labor has progressed to the transition phase.
b. She lacked adequate preparation for the labor experience.
c. The woman would benefit from a different form of analgesia.
d. The contractions have increased from mild to moderate intensity.
ANS: A
If a woman suddenly loses control and becomes irritable, suspect that she has progressed to
the transition stage of labor.
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DIF: Cognitive Level: Analysis REF: p. 155|Table 6-6
OBJ: 5 TOP: Transition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. What is the function of contractions during the second stage of labor?
a. Align the infant into the proper position for delivery
b. Dilate and efface the cervix
c. Push the infant out of the mother’s body
d. Separate the placenta from the uterine wall
ANS: C
The contractions push the infant out of the mother’s body as the second stage of labor ends
with the birth of the infant.
DIF: Cognitive Level: Knowledge REF: p. 155|Table 6-6
OBJ: 5 TOP: Second Stage of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. What marks the end of the third stage of labor?
a. Full cervical dilation
b. Expulsion of the placenta and membranes
c. Birth of the infant
d. Engagement of the head
ANS: B
The third stage of labor extends from the birth of the infant until the placenta is detached and
expelled. TESTBANKSELLER.COM
DIF: Cognitive Level: Knowledge REF: p. 155|Table 6-6
OBJ: 5 TOP: Third Stage of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. Why should the nurse encourage the mother to void during the fourth stage of labor?
a. A full bladder could interfere with cervical dilation.
b. A full bladder could obstruct progress of the infant through the birth canal.
c. A full bladder could obstruct the passage of the placenta.
d. A full bladder could predispose the mother to uterine hemorrhage.
ANS: D
A full bladder immediately after birth can cause excessive bleeding because it pushes the
uterus upward and interferes with contractions.
DIF: Cognitive Level: Comprehension REF: p. 155|Table 6-6
OBJ: 5 TOP: Nursing Care Immediately After Birth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14. The nurse observes the patient bearing down with contractions and crying out, “The baby is
coming!” What is the best nursing intervention?
a. Find the physician.
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