Labor & Delivery: Questions And Good Solutions
A nurse assesses a client during the third stage of labor. Which assessment
findings indicate that the client is experiencing postpartum hemorrhage?
✔️Ans - Heart rate 120 beats/minute, respiratory rate 28 breaths/minute,
blood pressure 80/40 mm Hg
A client in the first stage of labor is being monitored using an external fetal
monitor. A nurse notes variable decelerations on the monitoring strip. Into
what position should the nurse assist the client? ✔️Ans - lateral
A client with hemolysis, elevated liver enzymes, and low platelet count
(HELLP) syndrome is admitted to the labor and delivery unit. The client's
condition rapidly deteriorates and despite efforts by the staff, the client dies.
After the client's death, the nursing staff displays many emotions. Who should
the nurse manager consult to help the staff cope with this unexpected death?
1. The human resource director, so she can arrange vacation time for the staff
2. The physician, so he can provide education about HELLP syndrome
3. The social worker, so she can contact the family about funeral
arrangements and pass along the information to the nursing staff
4. The chaplain, because his educational background includes strategies for
handling grief ✔️Ans - Answer: 4
RATIONALES: The chaplain should be consulted because his educational
background provides strategies for helping others handle grief. Providing the
staff with vacation isn't feasible from a staffing standpoint and doesn't help
staff cope with their grief. The staff needs grief counseling, not education
about HELLP syndrome. Asking the social worker to contact the family about
the funeral arrangements isn't appropriate.
,Two clients arrive at the labor and delivery triage area at the same time. The
first client states that her water has been leaking, but that she hasn't had any
contractions. The second client says she's having 1-minute contractions every
3 minutes and that she feels like pushing. How should a nurse prioritize these
clients? ✔️Ans - The nurse should assign priority to the second client. Her
signs and symptoms indicate that her baby's birth is imminent.
A primigravid client in active labor has had no anesthesia. The client's cervix
is 7 cm dilated, and she is starting to feel considerable discomfort during
contractions. The nurse should instruct the client to change from slow chest
breathing to which breathing technique?
a) deep chest breathing
b) rapid pant-blow breathing
c) slow abdominal breathing
d) rapid, shallow chest breathing ✔️Ans - Rapid, shallow chest breathing
The psychoprophylaxis method of childbirth suggests using slow chest
breathing until it becomes ineffective during labor contractions, then
switching to shallow chest breathing (mostly at the sternum) during the peak
of a contraction. The rate is 50 to 70 breaths/min.
Deep chest breathing is appropriate for the early phase of labor, in which the
client exhibits less frequent contractions.
When transition nears, a rapid pant-blow pattern of breathing is used.
Slow abdominal breathing is very difficult for clients in labor.
While a 31-year-old multigravida at 39 weeks' gestation in active labor is
being admitted, her amniotic membranes rupture spontaneously. The client's
cervix is 5 cm dilated and the presenting part is at 0 station. Which of the
following should the nurse do first?
a) Prepare the client for imminent birth.
b) Note the color, amount, and odor of the amniotic fluid.
c) Auscultate the client's blood pressure.
, d) Perform a vaginal examination to determine dilation. ✔️Ans - Note the
color, amount, and odor of the amniotic fluid.
The primary health care provider orders an amniocentesis for a primigravid
client at 35 weeks' gestation in early labor to determine fetal lung maturity.
Which of the following is an indicator of fetal lung maturity? ✔️Ans -
Lecithin-sphingomyelin (L/S ratio).
A multigravid client is admitted at 4-cm dilation and is requesting pain
medication. The nurse gives the client nalbuphine 15 mg. Within five minutes,
the client tells the nurse she feels like she needs to have a bowel movement.
The nurse should first:
prepare for birth. complete a vaginal examination to determine dilation,
effacement, and station. have naloxone hydrochloride available in the birthing
room. document the client's relief due to pain medication. ✔️Ans -
Complete a vaginal examination to determine dilation, effacement, and station
The health care provider (HCP) plans to perform an amniotomy on a
multiparous client admitted to the labor area at 41 weeks' gestation for labor
induction. After the amniotomy, the nurse should first:
assess the client's temperature and pulse. document the color of the amniotic
fluid. monitor the client's contraction pattern. assess the fetal heart rate (FHR)
for 1 full minute. ✔️Ans - assess the fetal heart rate (FHR) for 1 full minute.
The nurse has provided an in-service presentation to ancillary staff about
standard precautions on the birthing unit. The nurse determines that one of
the staff members needs further instructions when the nurse makes which
observation?
a) placement of bloody sheets in a container designated for contaminated
linens
b) use of protective goggles during a cesarean birth
c) disposal of used scalpel blades in a puncture-resistant container
d) wearing of sterile gloves to bathe a neonate at 2 hours of age ✔️Ans -
wearing of sterile gloves to bathe a neonate at 2 hours of age
Correct
A nurse assesses a client during the third stage of labor. Which assessment
findings indicate that the client is experiencing postpartum hemorrhage?
✔️Ans - Heart rate 120 beats/minute, respiratory rate 28 breaths/minute,
blood pressure 80/40 mm Hg
A client in the first stage of labor is being monitored using an external fetal
monitor. A nurse notes variable decelerations on the monitoring strip. Into
what position should the nurse assist the client? ✔️Ans - lateral
A client with hemolysis, elevated liver enzymes, and low platelet count
(HELLP) syndrome is admitted to the labor and delivery unit. The client's
condition rapidly deteriorates and despite efforts by the staff, the client dies.
After the client's death, the nursing staff displays many emotions. Who should
the nurse manager consult to help the staff cope with this unexpected death?
1. The human resource director, so she can arrange vacation time for the staff
2. The physician, so he can provide education about HELLP syndrome
3. The social worker, so she can contact the family about funeral
arrangements and pass along the information to the nursing staff
4. The chaplain, because his educational background includes strategies for
handling grief ✔️Ans - Answer: 4
RATIONALES: The chaplain should be consulted because his educational
background provides strategies for helping others handle grief. Providing the
staff with vacation isn't feasible from a staffing standpoint and doesn't help
staff cope with their grief. The staff needs grief counseling, not education
about HELLP syndrome. Asking the social worker to contact the family about
the funeral arrangements isn't appropriate.
,Two clients arrive at the labor and delivery triage area at the same time. The
first client states that her water has been leaking, but that she hasn't had any
contractions. The second client says she's having 1-minute contractions every
3 minutes and that she feels like pushing. How should a nurse prioritize these
clients? ✔️Ans - The nurse should assign priority to the second client. Her
signs and symptoms indicate that her baby's birth is imminent.
A primigravid client in active labor has had no anesthesia. The client's cervix
is 7 cm dilated, and she is starting to feel considerable discomfort during
contractions. The nurse should instruct the client to change from slow chest
breathing to which breathing technique?
a) deep chest breathing
b) rapid pant-blow breathing
c) slow abdominal breathing
d) rapid, shallow chest breathing ✔️Ans - Rapid, shallow chest breathing
The psychoprophylaxis method of childbirth suggests using slow chest
breathing until it becomes ineffective during labor contractions, then
switching to shallow chest breathing (mostly at the sternum) during the peak
of a contraction. The rate is 50 to 70 breaths/min.
Deep chest breathing is appropriate for the early phase of labor, in which the
client exhibits less frequent contractions.
When transition nears, a rapid pant-blow pattern of breathing is used.
Slow abdominal breathing is very difficult for clients in labor.
While a 31-year-old multigravida at 39 weeks' gestation in active labor is
being admitted, her amniotic membranes rupture spontaneously. The client's
cervix is 5 cm dilated and the presenting part is at 0 station. Which of the
following should the nurse do first?
a) Prepare the client for imminent birth.
b) Note the color, amount, and odor of the amniotic fluid.
c) Auscultate the client's blood pressure.
, d) Perform a vaginal examination to determine dilation. ✔️Ans - Note the
color, amount, and odor of the amniotic fluid.
The primary health care provider orders an amniocentesis for a primigravid
client at 35 weeks' gestation in early labor to determine fetal lung maturity.
Which of the following is an indicator of fetal lung maturity? ✔️Ans -
Lecithin-sphingomyelin (L/S ratio).
A multigravid client is admitted at 4-cm dilation and is requesting pain
medication. The nurse gives the client nalbuphine 15 mg. Within five minutes,
the client tells the nurse she feels like she needs to have a bowel movement.
The nurse should first:
prepare for birth. complete a vaginal examination to determine dilation,
effacement, and station. have naloxone hydrochloride available in the birthing
room. document the client's relief due to pain medication. ✔️Ans -
Complete a vaginal examination to determine dilation, effacement, and station
The health care provider (HCP) plans to perform an amniotomy on a
multiparous client admitted to the labor area at 41 weeks' gestation for labor
induction. After the amniotomy, the nurse should first:
assess the client's temperature and pulse. document the color of the amniotic
fluid. monitor the client's contraction pattern. assess the fetal heart rate (FHR)
for 1 full minute. ✔️Ans - assess the fetal heart rate (FHR) for 1 full minute.
The nurse has provided an in-service presentation to ancillary staff about
standard precautions on the birthing unit. The nurse determines that one of
the staff members needs further instructions when the nurse makes which
observation?
a) placement of bloody sheets in a container designated for contaminated
linens
b) use of protective goggles during a cesarean birth
c) disposal of used scalpel blades in a puncture-resistant container
d) wearing of sterile gloves to bathe a neonate at 2 hours of age ✔️Ans -
wearing of sterile gloves to bathe a neonate at 2 hours of age
Correct
