Chapter 08: Nursing Care of Women with Complications During Labor and Birth
MULTIPLE CHOICE
1. What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. 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: Cognitive Level: Application REF: Page 176 OBJ: 3
TOP: Obstetric Procedures—Amniotomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce
labor and begins to have contractions every 90 seconds. What is the nurse’s initial action?
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: Cognitive Level: Application REF: Page 177 OBJ: 3
TOP: Obstetric Procedures—Induction of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. What nursing care should be provided to a woman with a third-degree laceration immediately
after delivery?
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
Ice is applied to the perineum to reduce bruising and edema.
DIF: Cognitive Level: Application REF: Page 180 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. What is this labor pattern
considered?
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: Cognitive Level: Comprehension REF: Page 187, Box 8-2
OBJ: 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to
5 cm with membranes intact. What action by the physician will the nurse anticipate?
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 REF: Page 176, 187
OBJ: 2|5 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. An infant is delivered with the use of forceps. What should the nurse assess for in the
newborn?
a.Loss of hair from contact with forceps
b.Sacral hematoma
c.Facial asymmetry
d.Shoulder dislocation
ANS: C
Pressure from forceps may injure the infant’s facial nerve, which is evidenced by facial
asymmetry.
DIF: Cognitive Level: Application REF: Page 181 OBJ: 3
TOP: Obstetric Procedures—Forceps Delivery
KEY: Nursing Process Step: Data Collection
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 responds, “This condition will resolve itself in a few days.” What is the
cause?
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
MULTIPLE CHOICE
1. What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. 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: Cognitive Level: Application REF: Page 176 OBJ: 3
TOP: Obstetric Procedures—Amniotomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce
labor and begins to have contractions every 90 seconds. What is the nurse’s initial action?
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: Cognitive Level: Application REF: Page 177 OBJ: 3
TOP: Obstetric Procedures—Induction of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. What nursing care should be provided to a woman with a third-degree laceration immediately
after delivery?
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
Ice is applied to the perineum to reduce bruising and edema.
DIF: Cognitive Level: Application REF: Page 180 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. What is this labor pattern
considered?
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: Cognitive Level: Comprehension REF: Page 187, Box 8-2
OBJ: 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to
5 cm with membranes intact. What action by the physician will the nurse anticipate?
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 REF: Page 176, 187
OBJ: 2|5 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. An infant is delivered with the use of forceps. What should the nurse assess for in the
newborn?
a.Loss of hair from contact with forceps
b.Sacral hematoma
c.Facial asymmetry
d.Shoulder dislocation
ANS: C
Pressure from forceps may injure the infant’s facial nerve, which is evidenced by facial
asymmetry.
DIF: Cognitive Level: Application REF: Page 181 OBJ: 3
TOP: Obstetric Procedures—Forceps Delivery
KEY: Nursing Process Step: Data Collection
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 responds, “This condition will resolve itself in a few days.” What is the
cause?
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
