Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 8th Edition
MULTIPLE CHOICE
1. What does the nurse note when measuring the frequency of a laboring woman’s contractions?
a. How long the patient states the contractions last
b. The time between the end of one contraction and the beginning of the next
c. The time between the beginning and the end of one contraction
d. The time between the beginning of one contraction and the beginning of the next
ANS: D
The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.
DIF: Cognitive Level: Comprehension
REF: p. 127
OBJ: 3
TOP: Frequency of Contractions
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Why is the relaxation phase between contractions important?
a. The laboring woman needs to rest.
b. The uterine muscles fatigue without relaxation.
c. The contractions can interfere with fetal oxygenation.
d. The infant progresses toward delivery at these times.
ANS: C
Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the
placenta refills with oxygenated blood for the fetus.
DIF: Cognitive Level: Comprehension
REF: p. 127
OBJ: 3
TOP: Interval
KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What contraction duration and interval does the nurse recognize could result in fetal compromise?
a. Duration shorter than 30 seconds, interval longer than 75 seconds
b. Duration shorter than 90 seconds, interval longer than 120 seconds
c. Duration longer than 90 seconds, interval shorter than 60 seconds
d. Duration longer than 60 seconds, interval shorter than 90 seconds
ANS: C
Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen
supply.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Comprehension
REF: p. 127|Safety Alert
4
TOP: Contraction/Fetal Compromise
Nursing Process Step: Data Collection
NCLEX: Physiological Integrity: Reduction of Risk
4. Vaginal examination reveals the presenting part is the infant’s head, which is well flexed on the chest. What is this presentation?
a. Vertex
b. Military
c. Brow
d. Face
ANS: A
In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.
DIF: Cognitive Level: Comprehension
REF: p. 129
OBJ: 3
TOP: Fetal Position
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?
a. Fetal distress
b. Fetal maturity
c. Intact gastrointestinal tract
d. Dehydration in the mother
ANS: A
Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.
DIF: Cognitive Level: Comprehension
REF: p. 144
OBJ: 4
TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
Copyright © 2019, Elsevier Inc. All Rights Reserved.
1
6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus’s hips are flexed and the knees are
extended. How would the nurse record this presentation?
a. Complete breech
b. Frank breech
c. Double footling
d. Buttocks presentation
ANS: B
When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Application
REF: p. 129|Figure 6-7
3|4
TOP: Components of the Birth Process
Nursing Process Step: Implementation
NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows that what indicates the
beginning of true labor?
a. Contractions that are relieved by walking
b. Discomfort in the abdomen and groin
c. A decrease in vaginal discharge
d. Regular contractions becoming more frequent and intense
ANS: D
In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Application
REF: p. 134|p. 137
6
TOP: Initiation of Labor
Nursing Process Step: Implementation
NCLEX: Physiological Integrity: Physiological Adaptation
8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. What
is the nurse’s most informative response?
a. “When you feel increased fetal movement”
b. “When contractions are 10 minutes apart”
c. “When membranes have ruptured”
d. “When abdominal or groin discomfort occurs”
ANS: C
Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Application
REF: p. 134|p. 137
5
TOP: Admission to the Hospital or Birth Center
Nursing Process Step: Implementation
NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this
stage of labor?
a. They get the infant positioned for delivery.
b. They push the infant into the vagina.
c. They dilate and efface the cervix.
d. They get the mother prepared for true labor.
ANS: C
The first stage of labor describes the time from the onset of labor until full dilation of the cervix.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Comprehension
REF: p. 155|Table 6-6
5
TOP: First Stage of Labor
Nursing Process Step: Data Collection
NCLEX: Physiological Integrity: Physiological Adaptation
10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse,
what does the nurse assess as the most likely explanation for the woman’s change in behavior?
a. Labor has progressed to the transition phase.
b. She lacked adequate preparation for the labor experience.
c. The woman would benefit from a different form of analgesia.
d. The contractions have increased from mild to moderate intensity.
ANS: A
If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.
DIF: Cognitive Level: Analysis
REF: p. 155|Table 6-6
OBJ: 5
TOP: Transition
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Copyright © 2019, Elsevier Inc. All Rights Reserved.
2
11. What is the function of contractions during the second stage of labor?
a. Align the infant into the proper position for delivery
b. Dilate and efface the cervix
c. Push the infant out of the mother’s body
d. Separate the placenta from the uterine wall
ANS: C
The contractions push the infant out of the mother’s body as the second stage of labor ends with the birth of the infant.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Knowledge
REF: p. 155|Table 6-6
5
TOP: Second Stage of Labor
Nursing Process Step: Implementation
NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. What marks the end of the third stage of labor?
a. Full cervical dilation
b. Expulsion of the placenta and membranes
c. Birth of the infant
d. Engagement of the head
ANS: B
The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Knowledge
REF: p. 155|Table 6-6
5
TOP: Third Stage of Labor
Nursing Process Step: Implementation
NCLEX: Physiological Integrity: Physiological Adaptation
13. Why should the nurse encourage the mother to void during the fourth stage of labor?
a. A full bladder could interfere with cervical dilation.
b. A full bladder could obstruct progress of the infant through the birth canal.
c. A full bladder could obstruct the passage of the placenta.
d. A full bladder could predispose the mother to uterine hemorrhage.
ANS: D
A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with
contractions.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Comprehension
REF: p. 155|Table 6-6
5
TOP: Nursing Care Immediately After Birth
Nursing Process Step: Implementation
NCLEX: Physiological Integrity: Reduction of Risk
14. The nurse observes the patient bearing down with contractions and crying out, “The baby is coming!” What is the best nursing
intervention?
a. Find the physician.
b. Stay with the woman and use the call bell to get help.
c. Send the woman’s partner to locate a registered nurse.
d. Assist with deep breathing to slow the labor process.
ANS: B
If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.
DIF: Cognitive Level: Application
REF: p. 135
OBJ: 5
TOP: Imminent Birth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does
this pattern indicate?
a. A well-oxygenated fetus
b. Compression of the umbilical cord
c. Compression of the fetal head
d. Uteroplacental insufficiency
ANS: A
Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.
DIF: Cognitive Level: Analysis
REF: p. 141
OBJ: 4
TOP: Fetal Accelerations
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Copyright © 2019, Elsevier Inc. All Rights Reserved.
3
16. What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push?
a. “At the beginning of a contraction, hold your breath and push for 10 seconds.”
b. “Take a deep breath and push between contractions.”
c. “Begin pushing when a contraction starts and continue for the duration of the
d.
contraction.”
“At the beginning of a contraction, take two deep breaths and push with the
second exhalation.”
ANS: D
When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take
another deep breath and push while exhaling.
DIF: Cognitive Level: Application
REF: p. 149
OBJ: 8
TOP: Instructions for Pushing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17. What is the most important nursing intervention during the fourth stage of labor?
a. Monitor the frequency and intensity of contractions.
b. Provide comfort measures.
c. Assess for hemorrhage.
d. Promote bonding.
ANS: C
Immediately after giving birth, every woman is assessed for signs of hemorrhage.
DIF: Cognitive Level: Comprehension
REF: p. 151
OBJ: 8
TOP: Postdelivery Hemorrhage
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. 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. 152
OBJ: 8
TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. 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
20. 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. 156
OBJ: 8
TOP: Ice Pack/Bruising
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Copyright © 2019, Elsevier Inc. All Rights Reserved.
4
21. 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:
OBJ:
KEY:
MSC:
Cognitive Level: Comprehension
REF: p. 158|Table 6-7
9
TOP: Care of the Infant After Birth
Nursing Process Step: Data Collection
NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. A nursing student assisting a woman in labor asks the instructor, “What does it mean when the baby is at minus 1 station?” After
being given an explanation by the nursing instructor, what statement by the student indicates an accurate understanding of station?
a. “Fetal head is above the ischial spines.”
b. “Fetal head is below the ischial spines.”
c. “Fetal head is engaged in the mother’s pelvis.”
d. “Fetal head is visible at the perineum.”
ANS: A
Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines.
Minus stations are above the ischial spines.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Comprehension
REF: p. 134|Figure 6-10
5
TOP: Mechanisms of Labor
Nursing Process Step: Evaluation
NCLEX: Physiological Integrity: Physiological Adaptation
23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
a. Pain related to increasing frequency and intensity of contractions.
b. Fear related to the probable need for cesarean delivery.
c. Dysuria related to prolonged labor and decreased intake.
d. Risk for injury related to hemorrhage.
ANS: D
In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
DIF:
TOP:
KEY:
MSC:
Cognitive Level: Application
REF: p. 152
OBJ: 5 | 8
Nursing Care Immediately After Birth
Nursing Process Step: Nursing Diagnosis
NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
24. The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical
effacement and intensify contractions in the patient?
a. By offering the patient warm fluids to drink
b. By helping the patient to ambulate in the room
c. By seating the patient upright in a straight-back chair
d. By positioning the patient on her right side
ANS: B
Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
DIF:
TOP:
KEY:
MSC:
Cognitive Level: Application
REF: p. 136
OBJ: 6 | 7 | 8
Differentiating Between True and False Labor
Nursing Process Step: Implementation
NCLEX: Physiological Integrity: Basic Care and Comfort
25. What is the best nursing action to implement when late decelerations occur?
a. Reposition the patient to supine.
b. Decrease flow of intravenous (IV) fluids.
c. Increase oxygen to 10 L/minute.
d. Prepare to increase oxytocin drip.
ANS: C
The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental
perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.
DIF: Cognitive Level: Application
REF: p. 142
OBJ: 8
TOP: Late Decelerations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
Copyright © 2019, Elsevier Inc. All Rights Reserved.
5
26. What is the nurse primarily concerned about maintaining in the initial care of the newborn?
a. Fluid intake
b. Feeding schedule
c. Thermoregulation
d. Parental bonding
ANS: C
Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which
leads to hypoxia.
DIF: Cognitive Level: Comprehension
REF: p. 157
OBJ: 9
TOP: Thermoregulation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
27. A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy.
What is the primary concern regarding complications for this patient during labor and birth?
a. Eclampsia
b. Placental abruption
c. Congestive heart failure
d. Uterine rupture
ANS: D
Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean births. The main
concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for
signs of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous
cesarean birth.
DIF: Cognitive Level: Comprehension
REF: p. 150
OBJ: 7
TOP: VBAC
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
28. The physician performs an amniotomy on a laboring woman. What will be the nurse’s priority assessment immediately following
this procedure?
a. Fetal heart rate
b. Fluid amount
c. Maternal blood pressure
d. Deep tendon reflexes
ANS: A
The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked
slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is
being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep
tendon reflexes are not appropriate assessments following rupture of membranes.
DIF: Cognitive Level: Application
REF: p. 144
OBJ: 8
TOP: Rupture of Membranes
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
1. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions? (Select all that
apply.)
a. Provide for extreme modesty.
b. Assign a male caregiver.
c. Arrange for the husband/partner to participate in labor.
d. Provide adequate pain control.
e. Respect protective amulets.
ANS: A, D, E
Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and religious amulets. The
husband is in attendance but not as a participant. Arabs prefer female caregivers. If a male is in attendance, then the husband will
remain in the room as long as the male is there.
DIF:
OBJ:
KEY:
MSC:
Cognitive Level: Application
REF: p. 123|Table 6-1
2
TOP: Cultural Considerations
Nursing Process Step: Planning
NCLEX: Psychosocial Integrity: Psychosocial Adaptation
2. What are the advantages of a freestanding birth center? (Select all that apply.)
a. Homelike setting
b. Designed for high-risk pregnancies
c. Lower costs
d. Attended by certified obstetricians
e. Immediate emergency access
ANS: A, C
Advantages of a freestanding birth center include a homelike setting and lower costs, because the center does not require expensive
departments such as emergency or critical care. Freestanding birth centers are not designed for high-risk patients, are not attended
by certified obstetricians, and do not have immediate emergency access.
DIF: Cognitive Level: Comprehension
REF: p. 122
OBJ: 2
TOP: Free-Standing Birth Centers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Copyright © 2019, Elsevier Inc. All Rights Reserved.
6
3. What do late decelerations indicate? (Select all that apply.)
a. A nonreassuring pattern
b. Uteroplacental insufficiency
c. Fetal heart depression
d. Cord compression
e. Head compression
ANS: A, B, C
This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord
compression and early decelerations indicate head compressions.
DIF: Cognitive Level: Comprehension
REF: p. 142
OBJ: 4 | 5
TOP: Late Decelerations
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After a thorough examination and
diagnostic testing, it is determined to be false (prodromal) labor. What signs and symptoms would lead the nurse to suspect false
(prodromal) labor?
a. Leaking of vaginal fluid
b. Contractions intensify with ambulation
c. Pink spotting
d. Painless tightening of abdominal muscles
e. Cervix thick and not effaced
ANS: D, E
Painless tightening of abdominal muscles (Braxton Hicks contractions) and cervix thick and not effaced lend to the determination
of false (prodromal) labor. Leaking of vaginal fluid may indicate rupture of membranes and is a sign of true labor. Contractions that
intensify with ambulation and pink spotting (bloody show) are signs of true labor.
DIF: Cognitive Level: Comprehension
REF: pp. 136-137 OBJ: 6 | 7
TOP: False Labor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
Copyright © 2019, Elsevier Inc. All Rights Reserved.
7