CHAPTER 16:

CHAPTER 16: MATERNAL CHILD NURSING FINAL STUDY TEST 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. 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. 3. 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 ANSWERANS: 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 patient 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 patient 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. 4. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's 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. 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 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 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 sterile glove while performing a vaginal examination for a laboring woman. 8. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: a. prepare the woman for imminent birth. b. notify the woman's primary health care provider. c. document the characteristics of the fluid. d. assess the fetal heart rate and pattern. - CORRECT ANSWER-ANS: D The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM. 9. A nulliparous woman who has just begun the second stage of her labor would most likely: a. experience a strong urge to bear down. b. show perineal bulging. c. feel tired yet relieved that the worst is over. d. show an increase in bright red bloody show. - CORRECT ANSWER-ANS: C Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because "the worst is over." During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor