QUESTIONS AND ANSWERS
A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the
following information about the woman should the nurse note from the woman's prenatal
record before proceeding with the physical assessment? Select all that apply.
1. Weight gain.
2. Ethnicity and religion. 3. Age.
4. Type of insurance.
5. Gravidity and parity. - ANS 1, 2, 3, and 5 are correct.
1. Before proceeding with a physical as-
sessment, the nurse should check the client's weight gain reported in her prenatal record.
2. The client's ethnicity and religion should be noted before physical assess- ment. This allows
the nurse to pro- ceed in a culturally sensitive manner.
3. The client's age should also be noted before the physical assessment is begun.
5. The client's gravidity and parity—how many times she has been pregnant and how many
times she has given birth—should also be noted before a physical assessment is begun.
2. A woman who states that she "thinks" she is in labor enters the labor suite. Which of the
following assessments will provide the nurse with the most valuable informa- tion regarding the
client's labor status?
1. Leopold's maneuvers.
2. Fundal contractility.
3. Fetal heart assessment.
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,4. Vaginal examination. - ANS 4. Vaginal Examination -
A vaginal examination will provide the nurse with the best information about the status of
labor.
A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was
talkative and excited at that time. During the past 10 minutes she has become serious, closing
her eyes and breathing rapidly with each contraction. Which of the following is an accurate
nursing assessment of the situation?
1. The client had poor childbirth education prior to labor.
2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and
hypercapnic.
4. The client needs her alpha-fetoprotein levels checked. - ANS 2. The client is exhibiting an
expected behavior for labor. -
The woman is showing expected signs of the active phase of labor.
A woman has just arrived at the labor and delivery suite. In order to report the client's status to
her primary health care practitioner, which of the following assess- ments should the nurse
perform? Select all that apply.
1. Fetal heart rate.
2. Contraction pattern. 3. Contraction stress test. 4. Vital signs.
5. Biophysical profile. - ANS 1, 2, and 4 are correct.
1. The nurse should assess the fetal
heart before reporting the client's
status to the health care provider.
2. The nurse should assess the contrac-
tion pattern before reporting the
client's status.
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,3. A contraction stress test is only performed if ordered by a health care practitioner.
4. The nurse should assess the woman's vital signs before reporting her status.
5. A biophysical profile is only performed if
ordered by a health care practitioner.
While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round
mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft
round mass just above the symphysis. Which of the fol- lowing is a reasonable conclusion by the
nurse?
1. The fetal position is transverse.
2. The fetal presentation is vertex.
3. The fetal lie is vertical.
4. The fetal attitude is flexed. - ANS 3.
With the findings of a hard round mass in the fundal area and soft round mass above the
symphysis, the nurse can conclude that the fetal lie is vertical.
When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-
risk woman, G1 P0000? Select all that apply.
1. After vaginal exams.
2. Before administration of analgesics.
3. Periodically at the end of a contraction. 4. Every ten minutes.
5. Before ambulating. - ANS 1, 2, 3, and 5 are correct.
1. The nurse should assess the fetal
heart after all vaginal exams.
2. The nurse should assess the fetal
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, heart before giving the mother any
analgesics.
3. The fetal heart should be assessed pe-
riodically at the end of a contraction.
4. The fetal heart pattern should be as- sessed every 1 hour during the latent phase of a low-
risk labor. It is not stan- dard protocol to assess every 10 minutes.
5. The nurse should assess the fetal heart before the woman ambulates.
The nurse is assessing the fetal station during a vaginal examination. Which of the following
structures should the nurse palpate?
1. Sacral promontory. 2. Ischial spines.
3. Cervix.
4. Symphysis pubis. - ANS 2. Station is assessed by palpating the ischial spines.
The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the
fundal region. A flat object is noted on the left and small objects are noted on the right of the
uterus. A hard round mass is noted above the symphysis. Which of the following positions is
consistent with these findings?
1. Left occipital anterior (LOA) 2. Left sacral posterior (LSP)
3. Right mentum anterior (RMA) 4. Right sacral posterior (RSP) - ANS 1. The nurse's findings
upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior po-
sition (LOA)—that is, the fetal back is felt on the mother's left side, the small parts are felt on
her right side, the buttocks are felt in the fundal re- gion, and the head is felt above her
symphysis.
A nurse is caring for a laboring woman who is in transition. Which of the following
signs/symptoms would indicate that the woman is progressing into the second stage of labor?
Select all that apply.
1. Bulging perineum.
2. Increased bloody show.
3. Spontaneous rupture of the membranes.
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