Lowdermilk Chapter 19: Nursing Care of the Family During Labor and Birth Study Guide Test.

Lowdermilk Chapter 19: Nursing Care of the Family During Labor and Birth Study Guide Test. 1. 1. Which statement by the client will assist the nurse in determining whether she is in true la- bor as opposed to false labor? a. C (Regular, strong contractions with the presence of cervical change indi- cate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but I passed some thick, pink this is not the indicator of true labor.) mucus when I urinated this morning. b. My bag of waters just broke. c. The contractions in my uterus are getting stronger and closer to- gether. d. My baby dropped, and I have to urinate more fre- quently now. 2. 2. When a nulliparous woman telephones the D (Assessment begins at the first contact with the woman, whether by hospital to report that telephone or in person. By asking the woman to describe her signs she is in labor, what guid- and symptoms, the nurse can begin her assessment and gather data. ance should the nurse provide or information should the nurse ob- tain? a. Tell the woman to stay home until her mem- branes rupture. b. Emphasize that food and fluid intake should stop. c. Arrange for the woman to come to the hospital for labor evaluation. d. Ask the woman to de- scribe why she believes she is in labor. 3. 3. The nurse is car- ing for a client in ear- The initial nursing activity should be to gather data about the womans status. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular. Before instructing the woman to come to the hospital, the nurse should initiate her assessment during the telephone interview. After this assessment has been made, the nurse may want to discuss the appropriate oral intake for early labor, such as light foods or clear liquids, depending on the preference of the client or her primary health care provider.) A (When the membranes rupture, microorganisms from the vagina can ly labor. Membranes rup- ascend into the amniotic sac, causing chorioamnionitis and placentitis. tured approximately 2 hours earlier. This client is at increased risk for which complication? a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension 4. 4. The uterine contrac- tions of a woman ear- ly in the active phase of labor are assessed by an internal uterine pres- ROM is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of the contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.) C (The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accom- plish the work of expelling the fetus and the placenta. In addition, the nurse documents these findings in the clients medical record. This sure catheter (IUPC). The labor pattern indicates that the client is in the active phase of the first uterine contractions oc- cur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more reg- ular and are moderate to stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the transition phase of the first strong. Based on this in- formation, what would a prudent nurse do next? a. Immediately notify the womans primary health care provider. b. Prepare to administer an oxytocic to stimulate uterine activity. c. Document the findings because they reflect the expected contraction