Test Bank For Maternal Child Nursing Care
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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 - 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 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 - 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
be expected to have the longest labor. The gravida 2 would be expected to have a
longer labor than the gravida 3, especially because her first labor was 16 hours.
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which
nursing interventions is most appropriate at this time?
A: inform the mother that the fetal heart rate is normal
B: reassess the fetal heart rate in 5 minutes because the rate is too high
C: report the fetal heart rate to the physician or nurse-midwife immediately
D: suggest to the mother that she is going to have a boy because the heart rate is fast -
A: inform the mother that the fetal heart rate is normal
The FHR is within the normal range, so no other action is indicated at this time. The
FHR is within the expected range; reassessment should occur, but not in 5 minutes.
The FHR is within the expected range; no further action is necessary at this point. The
gender of the baby cannot be determined by the FHR.
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 - 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 - 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 - 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 - C: a trickle of fluid from the vagina
Which clinical finding would be an indication to the nurse that the fetus may be
compromised?
A: active fetal movements
B: fetal heart rate in the 140s
C: contractions lasting 90 seconds
D: meconium-stained amniotic fluid - D: meconium-stained amniotic fluid
When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of
meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The
expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate
, contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of
adequate blood flow.
The nurse is caring for a low-risk patient in the active phase of labor. At which interval
should the nurse assess the fetal heart rate?
A: every 15 minutes
B: every 30 minutes
C: every 45 minutes
D: every 1 hour - B: every 30 minutes
For the fetus at low risk for complications, guidelines for frequency of assessments are
at least every 30 minutes during the active phase of labor. 15-minute assessments
would be appropriate for a fetus at high risk. 45-minute assessments during the active
phase of labor are not frequent enough to monitor for complications. 1-hour
assessments during the active phase of labor are not frequent enough to monitor for
complications.
Which nursing assessment indicates that a patient who is in the second stage of labor is
almost ready to give birth?
A: bloody mucous discharge increases
B: the vulva bulges and encircles the fetal head
C: the membranes rupture during a contraction
D: the fetal head is felt at 0 station during the vaginal examination - B: the vulva bulges
and encircles the fetal head
A bulging vulva that encircles the fetal head describes crowning, which occurs shortly
before birth. Bloody show occurs throughout the labor process and is not an indication
of an imminent birth. Rupture of membranes can occur at any time during the labor
process and does not indicate an imminent birth. Birth of the head occurs when the
station is +4. A zero station indicates engagement.
During labor a vaginal examination should be performed only when necessary because
of the risk of:
A: infection
B: fetal injury
C: discomfort
D: perineal trauma - A: infection
Vaginal examinations increase the risk of infection by carrying vaginal microorganisms
upward toward the uterus. Properly performed vaginal examinations should not cause
fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but
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latest updated
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 - 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 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 - 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
be expected to have the longest labor. The gravida 2 would be expected to have a
longer labor than the gravida 3, especially because her first labor was 16 hours.
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which
nursing interventions is most appropriate at this time?
A: inform the mother that the fetal heart rate is normal
B: reassess the fetal heart rate in 5 minutes because the rate is too high
C: report the fetal heart rate to the physician or nurse-midwife immediately
D: suggest to the mother that she is going to have a boy because the heart rate is fast -
A: inform the mother that the fetal heart rate is normal
The FHR is within the normal range, so no other action is indicated at this time. The
FHR is within the expected range; reassessment should occur, but not in 5 minutes.
The FHR is within the expected range; no further action is necessary at this point. The
gender of the baby cannot be determined by the FHR.
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 - 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 - 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 - 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 - C: a trickle of fluid from the vagina
Which clinical finding would be an indication to the nurse that the fetus may be
compromised?
A: active fetal movements
B: fetal heart rate in the 140s
C: contractions lasting 90 seconds
D: meconium-stained amniotic fluid - D: meconium-stained amniotic fluid
When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of
meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The
expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate
, contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of
adequate blood flow.
The nurse is caring for a low-risk patient in the active phase of labor. At which interval
should the nurse assess the fetal heart rate?
A: every 15 minutes
B: every 30 minutes
C: every 45 minutes
D: every 1 hour - B: every 30 minutes
For the fetus at low risk for complications, guidelines for frequency of assessments are
at least every 30 minutes during the active phase of labor. 15-minute assessments
would be appropriate for a fetus at high risk. 45-minute assessments during the active
phase of labor are not frequent enough to monitor for complications. 1-hour
assessments during the active phase of labor are not frequent enough to monitor for
complications.
Which nursing assessment indicates that a patient who is in the second stage of labor is
almost ready to give birth?
A: bloody mucous discharge increases
B: the vulva bulges and encircles the fetal head
C: the membranes rupture during a contraction
D: the fetal head is felt at 0 station during the vaginal examination - B: the vulva bulges
and encircles the fetal head
A bulging vulva that encircles the fetal head describes crowning, which occurs shortly
before birth. Bloody show occurs throughout the labor process and is not an indication
of an imminent birth. Rupture of membranes can occur at any time during the labor
process and does not indicate an imminent birth. Birth of the head occurs when the
station is +4. A zero station indicates engagement.
During labor a vaginal examination should be performed only when necessary because
of the risk of:
A: infection
B: fetal injury
C: discomfort
D: perineal trauma - A: infection
Vaginal examinations increase the risk of infection by carrying vaginal microorganisms
upward toward the uterus. Properly performed vaginal examinations should not cause
fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but
