Maternal-Newborn chapter 15 test bank
Questions with Accurate Answers
A 25-year-old primigravida patient is in the first stage of labor. She and her
husband have been holding hands and breathing together through each
contraction. Suddenly, the patient pushes her husband's hand away and shouts,
"Don't touch me?" This behavior is most likely:
A: a sign of abnormal labor progress
B: an indication that she needs analgesia
C: normal and related to hyperventilation
D: common during the transition phase of labor correct answer D: common
during the transition phase of labor
The transition phase of labor is often associated with an abrupt change in
behavior, including increased anxiety and irritability. This change of behavior is an
expected occurrence during the transition phase. If she is in the transitional phase
of labor, analgesia may not be appropriate if the birth is near. Hyperventilation
will produce signs of respiratory alkalosis.
A nursing priority during admission of a laboring patient who has not had prenatal
care is:
A: obtaining admission labs
B: identifying labor risk factors
C: discussing her birth plan choices
D: explaining importance of prenatal care correct answer B: identifying labor risk
factors
When a patient has not had prenatal care, the nurse must determine through
interviewing and examination the presence of any pregnancy or labor risk factors,
obtain admission labs, and discuss birth plan choices. Explaining the importance
of prenatal care can be accomplished after the patient's history has been
completed.
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 correct answer 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.
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum
unit. The fetal heart rate has been normal. Contractions are 5-9 minutes apart,
20-30 seconds in duration, and of mild intensity. Cervical dilation is 1-2 cm and
uneffaced (unchanged from admission). Membranes are intact. The nurse should
expect the patient to be:
A: discharged home with a sedative
B: admitted for extended observation
C: admitted and prepared for a cesarean birth
D: discharged home to await the onset of true labor correct answer D: discharged
home to await the onset of true labor
The situation describes a patient with normal assessments who is probably in
false labor and will probably not deliver rapidly once true labor begins. The
patient will probably be discharged, and there is no indication that a sedative is
needed. These are all indications of false labor; there is no indication that further
assessment or observations are indicated. These are all indications of false labor
without fetal distress. There is no indication that a cesarean birth is indicated.
A woman who is gravida 3, para 2 enters the intrapartum unit. The most
important nursing assessments include:
A: contraction pattern, amount of discomfort, and pregnancy history
Questions with Accurate Answers
A 25-year-old primigravida patient is in the first stage of labor. She and her
husband have been holding hands and breathing together through each
contraction. Suddenly, the patient pushes her husband's hand away and shouts,
"Don't touch me?" This behavior is most likely:
A: a sign of abnormal labor progress
B: an indication that she needs analgesia
C: normal and related to hyperventilation
D: common during the transition phase of labor correct answer D: common
during the transition phase of labor
The transition phase of labor is often associated with an abrupt change in
behavior, including increased anxiety and irritability. This change of behavior is an
expected occurrence during the transition phase. If she is in the transitional phase
of labor, analgesia may not be appropriate if the birth is near. Hyperventilation
will produce signs of respiratory alkalosis.
A nursing priority during admission of a laboring patient who has not had prenatal
care is:
A: obtaining admission labs
B: identifying labor risk factors
C: discussing her birth plan choices
D: explaining importance of prenatal care correct answer B: identifying labor risk
factors
When a patient has not had prenatal care, the nurse must determine through
interviewing and examination the presence of any pregnancy or labor risk factors,
obtain admission labs, and discuss birth plan choices. Explaining the importance
of prenatal care can be accomplished after the patient's history has been
completed.
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 correct answer 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.
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum
unit. The fetal heart rate has been normal. Contractions are 5-9 minutes apart,
20-30 seconds in duration, and of mild intensity. Cervical dilation is 1-2 cm and
uneffaced (unchanged from admission). Membranes are intact. The nurse should
expect the patient to be:
A: discharged home with a sedative
B: admitted for extended observation
C: admitted and prepared for a cesarean birth
D: discharged home to await the onset of true labor correct answer D: discharged
home to await the onset of true labor
The situation describes a patient with normal assessments who is probably in
false labor and will probably not deliver rapidly once true labor begins. The
patient will probably be discharged, and there is no indication that a sedative is
needed. These are all indications of false labor; there is no indication that further
assessment or observations are indicated. These are all indications of false labor
without fetal distress. There is no indication that a cesarean birth is indicated.
A woman who is gravida 3, para 2 enters the intrapartum unit. The most
important nursing assessments include:
A: contraction pattern, amount of discomfort, and pregnancy history
