Chapter 17: Nursing Care of the Family During Labour and Birth
MULTIPLE CHOICE
1. Which alerts the nurse that a woman is in true labour?
a. Passing thick, pink mucus
b. Rupture of membranes
c. Regular, strong contractions with cervical
dilation
d. Lightening
ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is
experiencing true labour. Loss of the mucous plug (operculum) often occurs during the first
stage of labour or before the onset of labour, but it is not the indicator of true labour.
Spontaneous rupture of membranes often occurs during the first stage of labour, but it is not
the indicator of true labour. The presenting part of the fetus typically becomes engaged in the
pelvis at the onset of labour, but this is not the indicator of true labour.
DIF: Cognitive Level: Comprehension REF: p. 416 |Patient Teaching
OBJ: Nursing Process: Assessment
2. Which would indicate that a woman has understood education related to the characteristics of
true labour?
a. Contractions stop when ambulating.
b. Contractions cause discomfort at the top
of the uterus.
c. Contractions are regular and get stronger
when ambulating.
d. Contractions are irregular but they are
getting stronger.
ANS: C
True labour contractions occur regularly, becoming stronger, lasting longer, and occurring
closer together. They may become intense during walking and continue despite comfort
measures. Typically, true labour contractions are felt in the lower back, radiating to the lower
portion of the abdomen. During false labour, contractions tend to be irregular and felt in the
, abdomen above the navel. Typically, during false labour, the contractions often stop with
walking or a change of position.
DIF: Cognitive Level: Application REF: p. 416 |Patient Teaching OBJ:
Nursing Process: Evaluation
3. When a nulliparous woman telephones the hospital to report that she is in labour, what should
the nurse do, initially?
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 labour evaluation.
d. Tell the woman to wait at home until
contractions are every 2 to 3 minutes
apart.
ANS: C
Assessment begins at the first contact with the woman, whether by telephone or in person.
Many hospitals discourage the nurse from giving advice regarding what to do because of legal
liability. Nurses are often instructed to tell women who call with questions to call their primary
health care provider or to come to the hospital if they feel the need to be checked. The
amniotic membranes may or may not spontaneously rupture during labour. 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 labour, such as light foods or clear
liquids, depending on the preference of the patient or her primary health care provider. The
nurse would not advise a woman who has not been assessed to stay at home until contractions
are 2 to 3 minutes apart.
DIF: Cognitive Level: Application REF: p. 416 OBJ: Nursing
Process: Assessment
4. What is an expected characteristic of amniotic fluid?
a. Deep yellow colour
, b. Pale, straw colour with small white
particles
c. Acidic result on a Nitrazine test
d. Absence of ferning
ANS: B
Amniotic fluid normally is a pale, straw-coloured fluid that may contain white flecks of vernix.
Yellow-stained fluid may indicate fetal hypoxia 36 hours before rupture of membranes, fetal
hemolytic disease, or intrauterine infection. Amniotic fluid produces an alkaline result on a
Nitrazine test. The presence of ferning is a positive indication of amniotic fluid.
DIF: Cognitive Level: Comprehension REF: p. 428 | Table 17-2
OBJ: Nursing Process: Assessment
5. When planning care for a labouring woman whose membranes have ruptured, the nurse
recognizes that the woman’s risk for which has increased?
a. Intrauterine infection
b. Hemorrhage
c. Precipitous labour
d. Supine hypotension
ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the amniotic
sac, causing 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 labour, it does not result in precipitous labour. ROM has no correlation with
supine hypotension.
DIF: Cognitive Level: Comprehension REF: p. 428
OBJ: Nursing Process: Diagnosis | Nursing Process: Planning
6. The uterine contractions of a woman early in the active phase of labour are assessed by an
internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at
the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to
10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55
to 60 seconds. On the basis of this information, what should the nurse do?
MULTIPLE CHOICE
1. Which alerts the nurse that a woman is in true labour?
a. Passing thick, pink mucus
b. Rupture of membranes
c. Regular, strong contractions with cervical
dilation
d. Lightening
ANS: C
Regular, strong contractions with the presence of cervical change indicate that the woman is
experiencing true labour. Loss of the mucous plug (operculum) often occurs during the first
stage of labour or before the onset of labour, but it is not the indicator of true labour.
Spontaneous rupture of membranes often occurs during the first stage of labour, but it is not
the indicator of true labour. The presenting part of the fetus typically becomes engaged in the
pelvis at the onset of labour, but this is not the indicator of true labour.
DIF: Cognitive Level: Comprehension REF: p. 416 |Patient Teaching
OBJ: Nursing Process: Assessment
2. Which would indicate that a woman has understood education related to the characteristics of
true labour?
a. Contractions stop when ambulating.
b. Contractions cause discomfort at the top
of the uterus.
c. Contractions are regular and get stronger
when ambulating.
d. Contractions are irregular but they are
getting stronger.
ANS: C
True labour contractions occur regularly, becoming stronger, lasting longer, and occurring
closer together. They may become intense during walking and continue despite comfort
measures. Typically, true labour contractions are felt in the lower back, radiating to the lower
portion of the abdomen. During false labour, contractions tend to be irregular and felt in the
, abdomen above the navel. Typically, during false labour, the contractions often stop with
walking or a change of position.
DIF: Cognitive Level: Application REF: p. 416 |Patient Teaching OBJ:
Nursing Process: Evaluation
3. When a nulliparous woman telephones the hospital to report that she is in labour, what should
the nurse do, initially?
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 labour evaluation.
d. Tell the woman to wait at home until
contractions are every 2 to 3 minutes
apart.
ANS: C
Assessment begins at the first contact with the woman, whether by telephone or in person.
Many hospitals discourage the nurse from giving advice regarding what to do because of legal
liability. Nurses are often instructed to tell women who call with questions to call their primary
health care provider or to come to the hospital if they feel the need to be checked. The
amniotic membranes may or may not spontaneously rupture during labour. 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 labour, such as light foods or clear
liquids, depending on the preference of the patient or her primary health care provider. The
nurse would not advise a woman who has not been assessed to stay at home until contractions
are 2 to 3 minutes apart.
DIF: Cognitive Level: Application REF: p. 416 OBJ: Nursing
Process: Assessment
4. What is an expected characteristic of amniotic fluid?
a. Deep yellow colour
, b. Pale, straw colour with small white
particles
c. Acidic result on a Nitrazine test
d. Absence of ferning
ANS: B
Amniotic fluid normally is a pale, straw-coloured fluid that may contain white flecks of vernix.
Yellow-stained fluid may indicate fetal hypoxia 36 hours before rupture of membranes, fetal
hemolytic disease, or intrauterine infection. Amniotic fluid produces an alkaline result on a
Nitrazine test. The presence of ferning is a positive indication of amniotic fluid.
DIF: Cognitive Level: Comprehension REF: p. 428 | Table 17-2
OBJ: Nursing Process: Assessment
5. When planning care for a labouring woman whose membranes have ruptured, the nurse
recognizes that the woman’s risk for which has increased?
a. Intrauterine infection
b. Hemorrhage
c. Precipitous labour
d. Supine hypotension
ANS: A
When the membranes rupture, microorganisms from the vagina can ascend into the amniotic
sac, causing 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 labour, it does not result in precipitous labour. ROM has no correlation with
supine hypotension.
DIF: Cognitive Level: Comprehension REF: p. 428
OBJ: Nursing Process: Diagnosis | Nursing Process: Planning
6. The uterine contractions of a woman early in the active phase of labour are assessed by an
internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at
the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to
10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55
to 60 seconds. On the basis of this information, what should the nurse do?
