Maternal-Newborn chapter 15 test bank
Which comfort measure should the nurse utilize a laboring woman to relax?
A: recommend frequent position changes
B: palpate her filling bladder every 15 minutes
C: offer warm wet cloths to use on the client's face and neck
D: keep the room lights lit so the client and her coach can see everything - ANS A:
recommend frequent position changes
Frequent maternal position changes reduce the discomfort from constant pressure and
promote fetal descent. A full bladder intensifies labor pain. The bladder should be
emptied every 2 hours. Women in labor become very hot and perspire. Cool cloths will
provide greater relief. Soft indirect lighting is more soothing than irritating bright lights.
Which assessment finding is an indication of hemorrhage in the recently delivered
postpartum patient?
A: elevated pulse rate
B: elevated blood pressure
C: firm funds at the midline
D: saturation of two perineal pads in 4 hours - ANS A: elevated pulse rate
An increasing pulse rate is an early sign of excessive blood loss. If the blood volume
were diminishing, the blood pressure would decrease. A firm fundus indicates that the
uterus is contracting and compressing the open blood vessels at the placental site.
Saturation of one pad within the first hour is the maximum normal amount of lochial flow.
Two pads within 4 hours is within normal limits.
Which intervention is an essential part of nursing care for a laboring patient?
A: helping the woman manage the pain
B: eliminating the pain associated with labor
C: feeling comfortable with the predictable nature of intrapartal care
, D: sharing personal experiences regarding labor and birth to decrease her anxiety -
ANS A: helping the woman manage the pain
Helping a patient manage the pain is an essential part of nursing care because pain is
an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully
relieved. The labor nurse should always be assessing for unpredictable occurrences.
Decreasing anxiety is important; however, managing pain is a top priority.
A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center
for evaluation when she experiences:
A: increased fetal movement
B: irregular contractions for 1 hour
C: a trickle of fluid from the vagina
D: thick pink or dark red vaginal mucus - ANS C: a trickle of fluid from the vagina
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring
evaluation for infection or cord compression. Decreased or the lack of fetal movement
requires further assessment. Irregular contractions are a sign of false labor and do not
require further assessment. Bloody show may occur before the onset of true labor. It
does not require professional assessment unless the bleeding is pronounced.
Which patient at term should proceed to the hospital or birth center the immediately
after labor begins?
A: gravida 2, para 1, who lives 10 minutes away
B: gravida 1, para 0, who lives 40 minutes away
C: gravida 2, para 1, whose first labor lasted 16 hours
D: gravida 3, para 2, whose longest previous labor was 4 hours - ANS D: gravida 3,
para 2, whose longest previous labor was 4 hours
Multiparous women usually have shorter labors than do nulliparous women. The woman
described in option D is multiparous with a history of rapid labors, increasing the
likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would
be expected to have a longer labor than the gravida in option C. The fact that she lives
close to the hospital allows her to stay home for a longer period of time. A gravida 1 will
Which comfort measure should the nurse utilize a laboring woman to relax?
A: recommend frequent position changes
B: palpate her filling bladder every 15 minutes
C: offer warm wet cloths to use on the client's face and neck
D: keep the room lights lit so the client and her coach can see everything - ANS A:
recommend frequent position changes
Frequent maternal position changes reduce the discomfort from constant pressure and
promote fetal descent. A full bladder intensifies labor pain. The bladder should be
emptied every 2 hours. Women in labor become very hot and perspire. Cool cloths will
provide greater relief. Soft indirect lighting is more soothing than irritating bright lights.
Which assessment finding is an indication of hemorrhage in the recently delivered
postpartum patient?
A: elevated pulse rate
B: elevated blood pressure
C: firm funds at the midline
D: saturation of two perineal pads in 4 hours - ANS A: elevated pulse rate
An increasing pulse rate is an early sign of excessive blood loss. If the blood volume
were diminishing, the blood pressure would decrease. A firm fundus indicates that the
uterus is contracting and compressing the open blood vessels at the placental site.
Saturation of one pad within the first hour is the maximum normal amount of lochial flow.
Two pads within 4 hours is within normal limits.
Which intervention is an essential part of nursing care for a laboring patient?
A: helping the woman manage the pain
B: eliminating the pain associated with labor
C: feeling comfortable with the predictable nature of intrapartal care
, D: sharing personal experiences regarding labor and birth to decrease her anxiety -
ANS A: helping the woman manage the pain
Helping a patient manage the pain is an essential part of nursing care because pain is
an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully
relieved. The labor nurse should always be assessing for unpredictable occurrences.
Decreasing anxiety is important; however, managing pain is a top priority.
A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center
for evaluation when she experiences:
A: increased fetal movement
B: irregular contractions for 1 hour
C: a trickle of fluid from the vagina
D: thick pink or dark red vaginal mucus - ANS C: a trickle of fluid from the vagina
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring
evaluation for infection or cord compression. Decreased or the lack of fetal movement
requires further assessment. Irregular contractions are a sign of false labor and do not
require further assessment. Bloody show may occur before the onset of true labor. It
does not require professional assessment unless the bleeding is pronounced.
Which patient at term should proceed to the hospital or birth center the immediately
after labor begins?
A: gravida 2, para 1, who lives 10 minutes away
B: gravida 1, para 0, who lives 40 minutes away
C: gravida 2, para 1, whose first labor lasted 16 hours
D: gravida 3, para 2, whose longest previous labor was 4 hours - ANS D: gravida 3,
para 2, whose longest previous labor was 4 hours
Multiparous women usually have shorter labors than do nulliparous women. The woman
described in option D is multiparous with a history of rapid labors, increasing the
likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would
be expected to have a longer labor than the gravida in option C. The fact that she lives
close to the hospital allows her to stay home for a longer period of time. A gravida 1 will
