1. After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse
immediately places the woman in which position?
A. supine
B. side-lying
C. sitting
D. knee–chest
Answer: D
Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would position the
woman in a modified Sims, Trendelenburg, or knee–chest position. Supine, side-lying, or sitting
would not provide relief of cord compression.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Reference: p. 778
2. A primigravida whose labor was initially progressing normally is now experiencing a decrease
in the frequency and intensity of her contractions. The nurse would assess the woman for which
condition?
A. a low-lying placenta
B. fetopelvic disproportion
C. contraction ring
D. uterine bleeding
Answer: B
Rationale: The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction
and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring,
or uterine bleeding would not be associated with a change in labor pattern.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 750
3. Which assessment finding will alert the nurse to be on the lookout for possible placental
abruption during labor?
A. macrosomia
B. gestational hypertension
C. gestational diabetes
D. low parity
Answer: B
Rationale: Risk factors for placental abruption include preeclampsia, gestational hypertension,
seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous
history of abruption, intimate partner violence, and placental pathology. Macrosomia, gestational
diabetes, and low parity are not considered risk factors.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 779
4. A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no
fetopelvic disproportion. Which group of medications would the nurse expect to administer?
A. sedatives
B. tocolytics
C. uterine stimulants
D. corticosteroids
Answer: C
Rationale: For hypotonic labor, a uterine stimulant such as oxytocin may be prescribed once
fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic
uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control
preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women
experiencing preterm labor.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Reference: p. 752
5. A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The
nurse would be alert for which possible effect in the newborn?
A. asphyxia
B. clavicular fracture
C. cephalhematoma
D. central nervous system injury
Answer: C
Rationale: Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as
ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput
succedaneum. Asphyxia may be related to numerous causes, but it is not associated with use of a
vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous
system injury is not associated with the use of a vacuum extractor.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 781
6. A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding
would require immediate intervention?
A. fetal heart rate of 150 beats/minute
B. contractions every 2 minutes, lasting 45 seconds
C. uterine resting tone of 14 mm Hg
D. urine output of 20 mL/hour
Answer: D
Rationale: Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is
below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is
within the accepted range of 120 to 160 beats/minute. Contractions should occur every 2 to 3
minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require
intervention.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Reference: p. 771
7. A woman with a history of crack cocaine use disorder is admitted to the labor and birth area.
While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the
abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is
continuous. Which condition would the nurse suspect?
A. amniotic fluid embolism
B. shoulder dystocia
C. uterine rupture
D. umbilical cord prolapse
Answer: C
Rationale: Uterine rupture is associated with crack cocaine use disorder. Generally, the first and
most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal
bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part.
Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress.
Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is
delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of
the presenting part of the fetus.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Physiological Adaptation
Reference: p. 779
8. A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and
maintains the infusion at the prescribed rate based on which finding?
A. Respiratory rate-16 breaths/minute
B. Decreased fetal heart rate variability
C. Urine output 22 mL/hour
D. Absent deep tendon reflexes
Answer: B
Rationale: A respiratory rate of 16 breaths per minute is appropriate and within acceptable
parameters to continue the infusion. When administering magnesium sulfate, the nurse would
immediately report decreaed fetal heart rate variability, a urine output less than 30 mL/hour, and
decreased or absent deep tendon reflexes.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process
Reference: p. 762
9. The nurse is reviewing the physical examination findings for a client who is to undergo labor
induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation
for labor induction?
A. posterior position
B. firm
C. closed
D. shortened
Answer: D
Rationale: A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An
unripe cervix is long, closed, posterior, and firm.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Health Promotion and Maintenance
Reference: p. 769
10. A woman with preterm labor is receiving magnesium sulfate. Which finding would require
the nurse to intervene immediately?
A. respiratory rate of 16 breaths per minute
B. 1+ deep tendon reflexes
C. urine output of 45 mL/hour
D. alert level of consciousness
Answer: B
Rationale: Diminished deep tendon reflexes (1+) suggest magnesium toxicity, which requires
immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less
than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of
consciousness.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Reference: p. 762
11. After teaching a couple about what to expect with their planned cesarean birth, which
statement indicates the need for additional teaching?
A. "Holding a pillow against my incision will help me when I cough."
B. "I'm going to have to wait a few days before I can start breastfeeding."
C. "I guess the nurses will be getting me up and out of bed rather quickly."
D. "I'll probably have a tube in my bladder for about 24 hours or so."
Answer: B
Rationale: Typically, breastfeeding is initiated early as soon as possible after birth to promote
bonding. The woman may need to use alternate positioning techniques to reduce incisional
discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing.
Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote
peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually
remains in place for approximately 24 hours.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 782
12. The nurse is providing care to several pregnant women who may be scheduled for labor
induction. The nurse identifies the woman with which Bishop score as having the best chance for
a successful induction and vaginal birth?
A. 11
B. 7
C. 5
D. 3
Answer: A
Rationale: The Bishop score helps identify women who would be most likely to achieve a
successful induction. The duration of labor is inversely correlated with the Bishop score: a score
over 8 indicates a successful vaginal birth. Therefore the woman with a Bishop score of 11
would have the greatest chance for success. Bishop scores of less than 6 usually indicate that a
cervical ripening method should be used prior to induction.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Understand
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process
Reference: p. 769
13. A nurse is reviewing the medical record of a pregnant client. The nurse suspects that the
client may be at risk for dystocia based on which factors? Select all that apply.
A. plan for pudendal block anesthetic use
B. multiparity
C. short maternal stature
D. Body mass index 30.2
E. breech fetal presentation
Answer: C, D, E
Rationale: Risk factors for dystocia may include maternal short stature, obesity, hydramnios,
uterine abnormalities, fetal malpresentation, cephalopelvic disproportion, overstimulation with
oxytocin, maternal exhaustion, ineffective pushing, excessive size fetus, poor maternal
positioning in labor, and maternal anxiety and fear
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 750
14. A nurse is preparing an inservice education program for a group of nurses about dystocia
involving problems with the passenger. Which problem would the nurse likely include as the
most common?
A. macrosomia
B. breech presentation
C. persistent occiput posterior position
D. multifetal pregnancy
Answer: C
Rationale: Common problems involving the passenger include occiput posterior position, breech
presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to cephalopelvic
disproportion (CPD), and structural anomalies. Of these, persistent occiput posterior is the most
common malposition, occurring in about 15% of laboring women.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Reference: p. 757
15. A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After
teaching the group, the nurse determines that the teaching was successful when they identify
which drugs as being used for tocolysis? Select all that apply.
A. nifedipine
B. magnesium sulfate
C. dinoprostone
D. misoprostol
E. indomethacin
Answer: A, B, E
Rationale: Medications most commonly used for tocolysis include magnesium sulfate (which
reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and
nifedipine (a calcium channel blocker). These drugs are used "off label": this means they are
effective for this purpose but have not been officially tested and developed for this purpose by
the FDA. Dinoprostone and misoprostol are used to ripen the cervix.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Reference: p. 762
16. A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she
experiences signs and symptoms. The nurse determines that the teaching was successful when
the woman makes which statement?
A. "I'll sit down to rest for 30 minutes."
B. "I'll try to move my bowels."
C. "I'll lie down with my legs raised."
D. "I'll drink several glasses of water."
Answer: D
Rationale: If the woman experiences any signs and symptoms of preterm labor, she should stop
what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three
glasses of water, feel her abdomen and note the hardness of the contraction, and call her health
care provider and describe the contraction.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 766
17. A nurse is describing the risks associated with post-term pregnancies as part of an inservice
presentation. The nurse determines thatmore teaching is needed when the group identifies which
factor as an underlying reason for problems in the fetus?
A. aging of the placenta
B. increased amniotic fluid volume
C. meconium aspiration
D. cord compression
Answer: B
Rationale: Fetal risks associated with a post-term pregnancy include macrosomia, shoulder
dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of
subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. As the
placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and
nutrients to the fetus. Amniotic fluid volume also begins to decline after 38 weeks’ gestation,
possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased
risk of cord compression because the cushioning effect offered by adequate fluid is no longer
present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is
released by the fetus in response to a hypoxic insult (Norwitz, 2019). All of these issues can
compromise fetal well-being and lead to fetal distress.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 767
18. A nurse is explaining to a group of nurses new to the labor and birth unit about methods used
for cervical ripening. The group demonstrates understanding of the information when they
identify which method as a mechanical one?
A. herbal agents
B. laminaria
C. membrane stripping
D. amniotomy
Answer: B
Rationale: Laminaria is a hygroscopic dilator that is used as a mechanical method for cervical
ripening. Herbal agents are a nonpharmacologic method. Membrane stripping and amniotomy
are considered surgical methods.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Health Promotion and Maintenance
Reference: p. 770
19. The nurse notifies the obstetrical team immediately because the nurse suspects that the
pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. When
reporting this suspicion, which finding(s) would the nurse include in the report? Select all that
apply.
A. significant difficulty breathing
B. hypertension
C. tachycardia
D. pulmonary edema
E. bleeding with bruising
Answer: A, C, D, E
Rationale: Anaphylactoid syndrome of pregnancy (ASP), also known as amniotic fluid
embolism, is an unforeseeable, life-threatening complication of childbirth. The etiology of ASP
remains an enigmatic, devastating obstetric condition associated with significant maternal and
newborn morbidity and mortality. It is a rare and often fatal event characterized by the sudden
onset of hypotension, cardiopulmonary collapse, hypoxia, and coagulopathy. ASP should be
suspected in any pregnant women with an acute onset of dyspnea, hypotension, and DIC. By
knowing how to intervene, the nurse can promote a better chance of survival for both the mother
and her newborn.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Physiological Adaptation
Reference: p. 780
20. A nurse is conducting an in-service program for a group of labor and birth unit nurses about
cesarean birth. The group demonstrates understanding of the information when they identify
which conditions as appropriate indications? Select all that apply.
A. active genital herpes infection
B. placenta previa
C. previous cesarean birth
D. prolonged labor
E. fetal distress
Answer: A, B, C, E
Rationale: The leading indications for cesarean birth are previous cesarean birth, breech
presentation, dystocia, and fetal distress. Examples of specific indications include active genital
herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental
abnormality (placenta previa or placental abruption), previous classic uterine incision or scar,
gestational hypertension, diabetes, positive human immunodeficiency virus (HIV) status, and
dystocia. Fetal indications include malpresentation (nonvertex presentation), congenital
anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Physiological Adaptation
Reference: p. 782
21. A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse
assesses the woman closely for which effect?
A. uterine hyperstimulation
B. headache
C. blurred vision
D. hypotension
Answer: A
Rationale: A major adverse effect of the obstetric use of misoprostol is hyperstimulation of the
uterus, which may progress to uterine tetany with marked impairment of uteroplacental blood
flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or
amniotic fluid embolism. Headache, blurred vision, and hypotension are associated with
magnesium sulfate.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Reference: p. 770
22. A nurse is teaching a woman about measures to prevent preterm labor in future pregnancies
because the woman just experienced preterm labor with her most recent pregnancy. The nurse
determines that the teaching was successful based on which statement by the woman?
A. "I'll make sure to limit the amount of long distance traveling I do."
B. "Stress isn't a problem that is related to preterm labor."
C. "Separating pregnancies by about a year should be helpful."
D. "I'll need extra iron in my diet so I have extra for the baby."
Answer: A
Rationale: Appropriate measures to reduce the risk for preterm labor include: avoiding travel for
long distances in cars, trains, planes or buses; achieving adequate iron store through balanced
nutrition (excess iron is not necessary); waiting for at least 18 months between pregnancies, and
using stress management techniques for stress.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Health Promotion and Maintenance
Reference: p. 766
23. A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is
having contractions sporadically. Which instructions would be most appropriate for the nurse to
give the woman? Select all that apply.
A. "Walk around the house for the next half hour."
B. "Drink two or three glasses of water."
C. "Lie down on your back."
D. "Try emptying your bladder."
E. "Stop what you are doing and rest."
Answer: B, D, E
Rationale: Appropriate instructions for the woman who may be experiencing preterm labor
include having the client stop what she is doing and rest for an hour, empty her bladder, lie down
on her left side, and drink two to three glasses of water.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 766
24. A pregnant client has received dinoprostone. Following administration of this medication, the
nurse assesses the client and determines that the client is experiencing an adverse effect of the
medication based on which client report? Select all that apply.
A. headache
B. nausea
C. diarrhea
D. tachycardia
E. hypotension
Answer: A, B, C
Rationale: Adverse effects associated with dinoprostone include headache, nauseas and
vomiting, and diarrhea. Tachycardia and hypotension are not associated with this drug.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Reference: p. 771
25. A nurse is reading a journal article about cesarean births and the indications for them. Place
the indications for cesarean birth below in the proper sequence from most frequent to least
frequent. All options must be used.
A. Labor dystocia
B. Abnormal fetal heart rate tracing
C. Fetal malpresentation
D. Multiple gestation
E. Suspected macrosomia
Answer: A, B, C, D, E
Rationale: The most common indications for primary cesarean births include, in order of
frequency: labor dystocia as the labor does not progress, abnormal fetal heart rate tracing
indicating fetal distress, fetal malpresentation making a difficult progression of labor, multiple
gestation , and suspected macrosomia.
Question format: Drag and Drop
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Analyze
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 750
26. A nurse is taking a history on a woman who is at 20 weeks' gestation. The woman reports
that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman
may be experiencing preterm labor based on which additional assessment findings? Select all
that apply.
A. dull low backache
B. viscous vaginal discharge
C. dysuria
D. constipation
E. occasional cramping
Answer: A, B, C
Rationale: Symptoms of preterm labor are often subtle and may include change or increase in
vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea,
vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a
sign of preterm labor. Preterm labor is assessed when there are more than six contractions per
hour. Occasional asymptomatic cramping can be normal.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Reference: p. 762
27. A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client
called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday
evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is
suspected. The nurse would expect to prepare the client for which testing to confirm the
suspicion?
A. Ultrasound
B. Amniocentesis
C. Human chorionic gonadotropin (hCG) level
D. Triple marker screening
Answer: A
Rationale: A client experiencing an intrauterine fetal demise (IUFD) is likely to seek care when
she notices that the fetus is not moving or when she experiences contractions, loss of fluid, or
vaginal bleeding. History and physical examination frequently are of limited value in the
diagnosis of fetal death, since many times the only history tends to be recent absence of fetal
movement and no fetal heart beat heard. An inability to obtain fetal heart sounds on examination
suggests fetal demise, but an ultrasound is necessary to confirm the absence of fetal cardiac
activity. Once fetal demise is confirmed, induction of labor or expectant management is offered
to the client. An amniocentesis, hCG level, or triple marker screening would not be used to
confirm IUFD.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 775
28. A 32-year-old black woman in her second trimester has come to the clinic for an evaluation.
While interviewing the client, she reports a history of fibroids and urinary tract infection. The
client states, "I know smoking is bad and I have tried to stop, but it is impossible. I have cut
down quite a bit though, and I do not drink alcohol." Complete blood count results reveal a low
red blood cell count, low hemoglobin, and low hematocrit. When planning this client's care,
which factor(s) would the nurse identify as increasing the client's risk for preterm labor? Select
all that apply.
A. African heritage
B. Maternal age
C. History of fibroids
D. Cigarette smoking
E. History of urinary tract infections
F. Complete blood count results
Answer: A, C, D, E, F
Rationale: For this client, risk factors associated with preterm labor and birth would include
African heritage, cigarette smoking, uterine abnormalities, such as fibroids, urinary tract
infection, and possible anemia based on her complete blood count results. Maternal age extremes
(younger than 16 years and older than 35 years) are also a risk factor but do not apply to this
client.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 761
29. A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she may be in
labor. To determine if the client is experiencing labor, which question(s) would be appropriate
for the nurse to ask? Select all that apply.
A. "Are you feeling any pressure or heaviness in your pelvis?"
B. "Are you having contractions that come and go, off and on?"
C. "Have you noticed any fluid leaking from your vagina?"
D. "Are you having problems with heartburn?"
E. "Have you been having any nausea or vomiting?"
Answer: A, B, C, E
Rationale: Frequently, women are unaware that uterine contractions, effacement, and dilation are
occurring, thus making early intervention ineffective in arresting preterm labor and preventing
the birth of a premature newborn. The nurse should ask the client about any signs/symptoms,
being alert for subtle symptoms of preterm labor, which may include: a change or increase in
vaginal discharge with mucous, water, or blood in it; pelvic pressure (pushing-down sensation);
low dull backache; menstrual-like cramps; urinary tract infection symptoms; feeling of pelvic
pressure or fullness; gastrointestinal upset like nausea, vomiting, and diarrhea; general sense of
discomfort or unease; heaviness or aching in the thighs; uterine contractions with or without
pain; more than six contractions per hour; intestinal cramping with or without diarrhea.
Contractions also must be persistent, such that four contractions occur every 20 minutes or eight
contractions occur in 1 hour. A report of heartburn is unrelated to preterm labor.
Question format: Multiple Select
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 761
30. When describing the stages of labor to a pregnant woman, which would the nurse identify as
the major change occurring during the first stage?
A. Regular contractions
B. Cervical dilation
C. Fetal movement through the birth canal
D. Placental separation
Answer: B
Rationale: The primary change occurring during the first stage of labor is progressive cervical
dilation. Contractions occur during the first and second stages of labor. Fetal movement through
the birth canal is the major change during the second stage of labor. Placental separation occurs
during the third stage of labor.
Question format: Multiple Choice
Chapter 21: Nursing Management of Labor and Birth at Risk
Cognitive Level: Apply
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Reference: p. 750