Chapter 21: the family in childbirth; needs & care
1) The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she
and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated
birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and
breathing techniques very successfully in her labor until the last 15 minutes. Now, during
contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's
back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the
plan of care for this client?
A) Fear/Anxiety related to discomfort of labor and unknown labor outcome
B) Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent
C) Coping: Family, Compromised, related to labor process
D) Knowledge, Deficient, related to lack of information about normal labor process and comfort
measures
Answer: B
2) A client is admitted to the labor and delivery unit with contractions that are regular, are 2
minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she
had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix
100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should
inform the client that she is in what phase of labor?
A) Latent phase
B) Active phase
C) Transition phase
D) Fourth stage
Answer: C
3) The nurse is assessing the comfort of the parents during the third stage of labor. Which
finding(s) indicate that the parents feel comfortable during this stage?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) Talking to the newborn
B) Verbally expressing feelings of pride
C) Requesting to dim the lights
D) Preferring limited contact with the newborn initially
E) Immediately placing phone calls
Answer: A, B
4) The nurse is caring for a client and her spouse during the third stage of labor. Which action(s)
support initial parental-newborn attachment at this time?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) Minimizing assessments
B) Delaying ophthalmic antibiotics for 2 hours
C) Dimming the room lights
D) Talking quietly
E) Providing privacy
Answer: A, C, D, E
5) The nurse is assessing the emotional state of a client following the delivery of her newborn.
Which response by the client requires further follow up by the nurse?
A) Excitability
B) Crying
C) Quiet
D) Withdrawn
Answer: D
6) The client presents to the labor and delivery unit stating that her water broke 2 hours ago.
Indicators of normal labor include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) Fetal heart rate of 130 with average variability
B) Blood pressure of 130/80
C) Maternal pulse of 160
D) Protein of +1 in urine
E) Odorless, clear fluid on underwear
Answer: A, B, E
7) The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's
partner asks why the fetus's heart rate will be monitored. After the nurse explains, which
statement by the partner indicates a need for further teaching?
A) "The fetus's heart rate will vary between 110 and 160."
B) "The heart rate is monitored to see whether the fetus is tolerating labor."
C) "By listening to the heart, we can tell the gender of the fetus."
D) "After listening to the heart rate, you will contact the midwife."
Answer: C
8) The laboring client and her partner have arrived at the birthing unit. Which step of the
admission process should be undertaken first?
A) The sterile vaginal exam
B) Welcoming the couple
C) Auscultation of the fetal heart rate
D) Checking for ruptured membranes
Answer: B
9) An expectant father has been at the bedside of his laboring partner for more than 12 hours. An
appropriate nursing intervention would be which of the following?
A) Insist that he leave the room for at least the next hour.
B) Tell him he is not being as effective as he was, and that he needs to let someone else take
over.
C) Offer to remain with his partner while he takes a break.
D) Suggest that the client's mother might be of more help.
Answer: D
10)By inquiring about the expectations and plans that a laboring woman and her partner have for
the labor and birth, the nurse is primarily doing which of the following?
A) Recognizing the client as an active participant in her own care.
B) Attempting to correct any misinformation the client might have received.
C) Acting as an advocate for the client.
D) Establishing rapport with the client.
Answer: A
11)The labor and birth nurse is admitting a client. The nurse's assessment includes asking the
client whom she would like to have present for the labor and birth, and what the client would
prefer to wear. The client's partner asks the nurse the reason for these questions. What would the
nurse's best response be?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) "These questions are asked of all women. It's no big deal."
B) "I'd prefer that your partner ask me all the questions, not you."
C) "A client's preferences for her birth are important for me to understand."
D) "Many women have beliefs about childbearing that affect these choices."
E) "I'm gathering information that the nurses will use after the birth."
Answer: C, D
12)The laboring client presses the call light and reports that her water has just broken. What
would the nurse's first action be?
A) Check fetal heart tones.
B) Encourage the mother to go for a walk.
C) Change bed linens.
D) Call the physician.
Answer: A
13)The laboring client is having moderately strong contractions lasting 60 seconds every 3
minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The
membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones
are in the 140s with accelerations to 150. Which nursing action has the highest priority?
A) Encourage the husband to remain in the room.
B) Keep the client on bed rest at this time.
C) Apply an internal fetal scalp electrode.
D) Obtain a clean-catch urine specimen.
Answer: B
14)The client has stated that she wants to avoid an epidural and would like an unmedicated birth.
Which nursing action is most important for this client?
A) Encourage the client to vocalize during contractions.
B) Perform vaginal exams only between contractions.
C) Provide a CD of soft music with sounds of nature.
D) Offer to teach the partner how to massage tense muscles.
Answer: D
15)The nurse is reviewing the contents of the birthing unit's emergency pack for use in case of a
precipitous birth. Which item(s) should the nurse ensure is (are) included in the pack?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) Sterile drape
B) Bulb syringe
C) Two sterile clamps
D) Sterile gloves
E) Forceps
Answer: A, B, C, D
16)Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What
is the first action the nurse would take?
A) Massage the fundus until firm
B) Express retained clots
C) Increase the intravenous solution
D) Call the physician
Answer: A
17)Why is it important for the nurse to assess the bladder regularly and encourage the laboring
client to void frequently?
A) A full bladder impedes oxygen flow to the fetus.
B) Frequent voiding prevents bruising of the bladder.
C) Frequent voiding encourages sphincter control.
D) A full bladder can impede fetal descent.
Answer: D
18)The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness,
and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of
the following?
A) Hyperventilation
B) Seizure auras
C) Imminent birth
D) Anxiety
Answer: A
19)A client who wishes to have an unmedicated birth is in the transition stage. She is very
uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How
can the nurse be most helpful?
A) Talk to the client the entire time.
B) Turn on the television to distract the client.
C) Stand next to the bed with hands on the railing next to the client.
D) Sit silently in the room away from the bed.
Answer: C
20)The nurse administered oxytocin 20 units at the time of placental delivery. Why was this
primarily done?
A) To contract the uterus and minimize bleeding
B) To decrease breast milk production
C) To decrease maternal blood pressure
D) To increase maternal blood pressure
Answer: A
21)A client delivered 30 minutes ago. Which post partal assessment finding would require close
nursing attention?
A) A soaked perineal pad since the last 15-minute check
B) An edematous perineum
C) The client experiencing tremors
D) A fundus located at the umbilicus
Answer: A
22)The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is
crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are
flexed and resist straightening. What should the nurse record as this infant's Apgar score?
A) 7
B) 8
C) 9
D) 10
Answer: B
23)Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the
nurse is doing this. What should the nurse reply?
A) "I'm checking the blood vessels in the cord to see whether it has one artery and one vein."
B) "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein."
C) "I'm checking the blood vessels in the cord to see whether it has two veins and one artery."
D) "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins."
Answer: B
24)At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying
vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant
cries easily when the soles of the feet are stimulated. How would the nurse document this infant's
Apgar score?
A) 7
B) 8
C) 9
D) 10
Answer: C
25)Upon delivery of the newborn, what nursing intervention most promotes parental attachment?
A) Placing the newborn under the radiant warmer.
B) Placing the newborn on the mother's abdomen.
C) Allowing the mother a chance to rest immediately after delivery.
D) Taking the newborn to the nursery for the initial assessment.
Answer: B
26)A young adolescent is transferred to the labor and delivery unit from the emergency
department. The client is in active labor but did not know she was pregnant. What is the most
important nursing action?
A) Determine who might be the father of the baby for paternity testing.
B) Ask the client what kind of birthing experience she would like to have.
C) Assess blood pressure and check for proteinuria.
D) Obtain a Social Services referral to discuss adoption.
Answer: C
27)As compared with admission considerations for an adult woman in labor, the nurse's priority
for an adolescent in labor would be which of the following?
A) Cultural background
B) Plans for keeping the infant
C) Support persons
D) Developmental level
Answer: D
28)An abbreviated systematic physical assessment of the newborn is performed by the nurse in
the birthing area to detect any abnormalities. Normal findings would include which of the
following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) Skin color: Body blue with pinkish extremities
B) Umbilical cord: two veins and one artery
C) Respiration rate of 30-60 irregular
D) Temperature of above 36.5°C (97.8°F)
E) Sole creases that involve the heel
Answer: C, D, E
29)A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the
nurse do?
A) Go to the nurse's station and immediately call the physician.
B) Run to the delivery room for an emergency birth pack.
C) Stay with the client and ask auxiliary personnel for assistance.
D) Hold back the infant's head forcibly until the physician arrives for the delivery.
Answer: C
30)The nurse has completed an initial physical assessment for a client admitted to the birthing
unit. Which action should the nurse take next?
A) Obtain the client's social history
B) Document the physical assessment findings
C) Report findings to the physician
D) Perform interventions for pain management
Answer: A
31)The nurse has taken a detailed social history from a client admitted to the birthing unit. Which
insights may the nurse gain as a result of this assessment?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
A) Social habits
B) Psychologic factors
C) Presence of HIV
D) Readiness for discharge
E) Need for bed rest
Answer: A, B
32)A newborn has the following applied to the umbilical cord. What should the nurse instruct the
new parents about regarding this device?
A) It has to stay intact for at least one week
B) It is removed in 24 hours if the cord has dried
C) It eliminates the need to wash the infant's abdomen
D) It is removed by cutting the tissue beneath the clamp
Answer: B
33)The nurse determines that a newborn has the following findings:
Heart rate: 88 beats per minute
Respirations: 24 per minute and irregular
Muscle tone: Minor movement of lower extremities
Reflex response: Grimace
Skin color: Pink body, blue extremities
If using the following table, what action should the nurse take at this
A) Begin resuscitation
B) Stimulate the infant
C) Document the findings
D) Nasopharyngeal suctioning
Answer: B
34)The nurse is observed performing the following with a patient:
What information will this assessment technique provide to the nurse?
A) Assesses for bladder distention
B) Estimates the weight of the uterus
C) Determines the height of the fundus
D) Evaluates the remaining placenta contents
Answer: C