Chapter 06: Nursing Care of Mother and Infant
During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is
the most appropriate nursing action?
a. Check the fundus for position and firmness.
b. Report to the doctor immediately.
c. Change the pads and chart the time.
d. Time how long it takes to soak one pad.
ANS: A
Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One
pad an hour is an acceptable rate for immediate postdelivery.
DIF: Cognitive Level: Application REF: p. 153 OBJ: 8
TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal
heart rate with uterine contractions. What is the nurse‘s initial action?
a. Stop the oxytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
d. Start oxygen via nasal cannula.
ANS: C
, Repositioning the woman is the first response to a pattern of variable decelerations. If the
decelerations continue, then oxygen should be administered and/or the flow rate of oxygen
should be increased.
DIF: Cognitive Level: Application REF: p. 142 OBJ: 8
TOP: Variable Decelerations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
3. How should the nurse intervene to relieve perineal bruising and edema following delivery?
a. Place an ice pack on the area for 12 hours.
b. Place a warm pack on the perineal area for 24 hours.
c. Administer aspirin to relieve inflammation.
d. Change the perineal pad frequently.
ANS: A
An ice pack can be placed on the mother‘s perineum to reduce bruising and edema for 12
hours followed by a warm pack after the first 12 to 24 hours after delivery.
DIF: Cognitive Level: Application REF: p. 153 OBJ: 8
TOP: Ice Pack/Bruising KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. At 1 and 5 minutes of life, a newborn‘s Apgar score is 9. What does the nurse understand that a
score of 9 indicates?
a. The newborn will require resuscitation.
b. The newborn may have physical disabilities.
c. The newborn will have above average intelligence.
d. The newborn is in stable condition.
ANS: D
Apgar scoring is a system for evaluating the infant‘s need for resuscitation at birth. Five
categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9
indicates that the newborn is stable.
DIF: Cognitive Level: Comprehension REF: p. 158 | Table 6.6
OBJ: 9 TOP: Care of the Infant After Birth
During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is
the most appropriate nursing action?
a. Check the fundus for position and firmness.
b. Report to the doctor immediately.
c. Change the pads and chart the time.
d. Time how long it takes to soak one pad.
ANS: A
Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One
pad an hour is an acceptable rate for immediate postdelivery.
DIF: Cognitive Level: Application REF: p. 153 OBJ: 8
TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal
heart rate with uterine contractions. What is the nurse‘s initial action?
a. Stop the oxytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
d. Start oxygen via nasal cannula.
ANS: C
, Repositioning the woman is the first response to a pattern of variable decelerations. If the
decelerations continue, then oxygen should be administered and/or the flow rate of oxygen
should be increased.
DIF: Cognitive Level: Application REF: p. 142 OBJ: 8
TOP: Variable Decelerations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
3. How should the nurse intervene to relieve perineal bruising and edema following delivery?
a. Place an ice pack on the area for 12 hours.
b. Place a warm pack on the perineal area for 24 hours.
c. Administer aspirin to relieve inflammation.
d. Change the perineal pad frequently.
ANS: A
An ice pack can be placed on the mother‘s perineum to reduce bruising and edema for 12
hours followed by a warm pack after the first 12 to 24 hours after delivery.
DIF: Cognitive Level: Application REF: p. 153 OBJ: 8
TOP: Ice Pack/Bruising KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. At 1 and 5 minutes of life, a newborn‘s Apgar score is 9. What does the nurse understand that a
score of 9 indicates?
a. The newborn will require resuscitation.
b. The newborn may have physical disabilities.
c. The newborn will have above average intelligence.
d. The newborn is in stable condition.
ANS: D
Apgar scoring is a system for evaluating the infant‘s need for resuscitation at birth. Five
categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9
indicates that the newborn is stable.
DIF: Cognitive Level: Comprehension REF: p. 158 | Table 6.6
OBJ: 9 TOP: Care of the Infant After Birth
