Maternity Nursing An Introductory Text 11th Edition By Gloria Leifer -Test Bank

Maternity Nursing An Introductory Text 11th Edition By Gloria Leifer -Test Bank

Leifer: Maternity Nursing: An Introductory Text, 11th Edition

Chapter 06: Process of Normal Labor

Test Bank

MULTIPLE CHOICE

1. During childbirth education, a woman should be advised that she may have a sudden gush of fluid from the vagina as she approaches her expected delivery date. Which statement best explains this event?
a. The fluid, often called bloody show, is caused by the expulsion of a protective mucous plug from the cervix.
b. This loss of fluid is usually related to overexertion during the sudden burst of energy that often occurs shortly before labor begins.
c. Rupture of amniotic membranes allows the amniotic fluid to flow from the uterus through the vagina.
d. The passage of fluid eliminates excess water in preparation for the process of labor.

ANS: C
Rupture of the amniotic membranes (ROM) permits amniotic fluid to pass through the vagina. Women commonly go into labor within 24 hours after ROM. If the membranes do not rupture spontaneously, the physician may rupture them artificially. Artificial rupture of the membranes is useful in inducing labor if it does not begin spontaneously.

DIF: Cognitive Level: Application REF: 99 OBJ: 3
TOP: Spontaneous Rupture of Membranes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

2. As she nears her expected delivery date, a woman reports that she is breathing more easily but now has to urinate frequently. The nurse should explain to her that:
a. The symptoms are typical of false labor.
b. Cervical dilation puts pressure on the bladder.
c. She needs a urinalysis to rule out a bladder infection.
d. This is “lightening” caused by the fetus moving downward in the pelvis.

ANS: D
As the uterus descends into the maternal pelvis, pressure on the diaphragm decreases and pressure on the bladder increases. Therefore, breathing becomes easier and the woman feels the need to void often.

DIF: Cognitive Level: Application REF: 98 OBJ: 2
TOP: Lightening KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

3. Several hours after she was admitted in early labor, a woman’s cervix is dilated 4 cm. This is significant because:
a. The woman’s labor will probably progress to completion.
b. The cervix is almost completely dilated.
c. It means effacement is complete.
d. The mucous plug will come out.

ANS: A
Once the cervix dilates to 4 cm, labor will probably progress to completion. Complete dilation is 10 cm. Dilation is a measure of the cervical opening, not cervical effacement. The mucous plug would have been expelled earlier than this.

DIF: Cognitive Level: Comprehension REF: 96 OBJ: 2
TOP: Effect of Contractions on Cervix KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

4. After examining the laboring woman, the physician tells her that her cervix showed some effacement. Later, the woman asks the nurse what “effacement” is. Effacement is best described as:
a. Enlargement of the cervical os to permit the fetus to pass through
b. Relaxation and stretching of perineal muscles
c. Shortening and thinning of the cervix
d. Loss of the mucous plug

ANS: C
The uterus is normally pear shaped, with the cervix at the narrow end. As labor progresses, the cervix becomes shorter and thinner. This is called effacement.

DIF: Cognitive Level: Comprehension REF: 96 OBJ: 2
TOP: Effect of Contractions on Cervix KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

5. True labor is differentiated from false labor by:
a. Dilation of the cervix
b. Intensity of the contractions
c. Duration of the contractions
d. Amount of vaginal discharge

ANS: A
Although true and false labors have similarities, cervical dilation is present with true labor but not with false labor.

DIF: Cognitive Level: Knowledge REF: 99 OBJ: 8
TOP: False Labor KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

6. A group of postpartum women are discussing their experiences in labor and delivery. Which statement by a new mother best describes fetal presentation?
a. “My baby’s head was too large to descend.”
b. “The doctor said my baby was crosswise in my uterus.”
c. “My baby was breech, so I had to have a cesarean section.”
d. “My labor was long because the back of the baby’s head was directed toward my backbone.”

ANS: C
Fetal presentation refers to the fetal body part that is lowest in the pelvis. Examples of presentation are cephalic (head), breech (buttocks or foot), and shoulder.

DIF: Cognitive Level: Comprehension REF: 92-93 OBJ: 10
TOP: Fetal Presentation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

7. If the fetal position recorded on the woman’s chart is RMP, what is the presenting part of the fetus?
a. Head
b. Shoulder
c. Face
d. Sacrum

ANS: C
In the classification RMP (right mentum posterior), the middle letter is the presenting part. M stands for mentum, which means chin. It is used to describe the face.

DIF: Cognitive Level: Comprehension REF: 93-95 | Box 6-1
OBJ: 11 TOP: Fetal Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

8. The relationship of the presenting part to the ischial spines of the pelvis is called:
a. Engagement
b. Station
c. Flexion
d. Position

ANS: B
Station is defined as the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis.

DIF: Cognitive Level: Knowledge REF: 93-95 OBJ: 12
TOP: Station KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

9. The presenting part of the fetus becomes engaged in the pelvis when it reaches the level of the:
a. Ischial tuberosities
b. Ischial spines
c. True pelvis
d. False pelvis

ANS: B
Engagement is said to occur when the presenting part is level with the ischial spines. At this point, the widest diameter of the fetal head has entered the inlet of the pelvis.

DIF: Cognitive Level: Knowledge REF: 94-95 OBJ: 12
TOP: Station KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

10. If the fetal head is directed downward in the lower part of the uterus with the occiput on the left anterior side of the maternal pelvis, the position is termed:
a. ROP
b. ROA
c. LOP
d. LOA

ANS: D
L refers to the left side of the maternal pelvis, O refers to the presenting part (occiput), and A refers to the anterior of the maternal pelvis.

DIF: Cognitive Level: Comprehension REF: 93-95 | Box 6-1
OBJ: 11 TOP: Fetal Position KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

11. During a uterine contraction, the blood flow through the uterine arteries and intervillous spaces:
a. Increases
b. Decreases
c. Remains the same
d. Is shunted to the fetus

ANS: B
Contraction of uterine muscle puts pressure on the uterine arteries and intervillous spaces, which obstructs blood flow.

DIF: Cognitive Level: Comprehension REF: 96 OBJ: 6
TOP: The Uterine Contraction KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiologic Integrity

12. While assessing a woman’s contractions during labor, the nurse records a frequency of 5 minutes, which means:
a. Each contraction lasts 5 minutes from the beginning to the end.
b. At the peak of a contraction, the fundus is very firm and cannot be indented.
c. Five minutes elapse between the start of one contraction and the start of the next contraction.
d. Five minutes elapse between the end of one contraction and the beginning of the next contraction.

ANS: C
Frequency refers to the time between the onset of one contraction and the onset of the next contraction.

DIF: Cognitive Level: Application REF: 96 | 98 OBJ: 7
TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

13. Which sequence presents the mechanisms of labor in the correct order?
a. Flexion, descent, internal rotation, extension, external rotation
b. Descent, flexion, internal rotation, extension, expulsion
c. Descent, flexion, internal rotation, extension, external rotation, expulsion
d. Flexion, internal rotation, extension, expulsion

ANS: C
Descent, flexion, internal rotation, extension, external rotation, expulsion is the correct sequence of the mechanisms of labor.

DIF: Cognitive Level: Comprehension REF: 99-101 | Figure 6-7
OBJ: 14 TOP: Mechanisms of Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

14. What occur(s) during the first stage of labor?
a. Cervical effacement and dilation
b. Recovery period
c. Birth of the baby
d. Expulsion of the placenta

ANS: A
In the first stage of labor, regular contractions are established and the cervix dilates and effaces.

DIF: Cognitive Level: Knowledge REF: 101 OBJ: 14
TOP: Four Stages of Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

15. A laboring patient tells the nurse that she needs to have a bowel movement. The nurse recognizes that the woman is most likely in which stage of labor?
a. Active first stage
b. Second stage
c. Third stage
d. Fourth stage

ANS: B
There is a strong urge to bear down (as if with a bowel movement) in the second stage of labor.

DIF: Cognitive Level: Analysis REF: 101-102 | Box 6-2
OBJ: 14 TOP: Four Stages of Labor
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

16. What occur(s) during the third stage of labor?
a. Recovery period
b. Birth of the baby
c. Expulsion of the placenta
d. Effacement and dilation

ANS: C
The third stage of labor is known as the placental separation stage because that is when the placenta separates from the uterus and is delivered.

DIF: Cognitive Level: Knowledge REF: 102 OBJ: 14
TOP: Four Stages of Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

17. The nurse is caring for a woman during the first hour after delivery. It is most critical to assess her:
a. Respirations and temperature
b. Vaginal bleeding and uterine firmness
c. Bowel sounds and lung sounds
d. Knowledge of breastfeeding and infant care

ANS: B
In the early part of the fourth stage of labor, the uterus must remain contracted to compress the open blood vessels and prevent excessive bleeding. Assessment of bleeding and uterine firmness is critical to detect hemorrhage.

DIF: Cognitive Level: Application REF: 102 OBJ: 14
TOP: Four Stages of Labor KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity

18. What is a normal physiologic change during labor?
a. White blood cell count increases.
b. There is an increase in muscle size caused by exertion.
c. Gastrointestinal motility is increased.
d. Estrogen decreases and progesterone increases.

ANS: A
During labor, gastrointestinal motility slows, white blood cells increase, muscle tissue breaks down, estrogen increases, and progesterone decreases.

DIF: Cognitive Level: Comprehension REF: 103-104 | Table 6-2
OBJ: 15 TOP: Physiologic Changes in Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

19. What represents the usual sequence of neurologic responses to labor?
a. Amnesia, euphoria, sedation, self-centeredness, fatigue
b. Euphoria, amnesia, self-centeredness, fatigue, elation
c. Self-centeredness, fatigue, elation, euphoria, amnesia
d. Euphoria, self-centeredness, amnesia, fatigue, elation

ANS: D
The woman’s behavior commonly changes throughout the course of her labor. Initially, she tends to be euphoric, then self-centered. In the second stage, amnesia is common. Fatigue and elation occur in the third and fourth stages.

DIF: Cognitive Level: Comprehension REF: 103-104 | Table 6-2
OBJ: 15 TOP: Physiologic Changes in Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

20. A woman in active labor complains of feeling “dizzy and faint.” When the nurse checks her blood pressure, she or he finds that the reading is lower than previous readings. Based on the nurse’s inference, the first nursing action should be to:
a. Lower the bed to the Trendelenburg position.
b. Turn the patient to her left side.
c. Recheck her blood pressure to verify accuracy of reading.
d. Report this episode to the midwife or physician.

ANS: B
Lying on the back places pressure on the mother’s blood vessels and can cause decreased cardiac output and blood pressure. This is referred to as supine hypotensive syndrome.

DIF: Cognitive Level: Analysis REF: 103 | Table 6-2
OBJ: 15 TOP: Physiologic Changes in Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiologic Integrity

21. The nurse has received a report about a woman in labor. The woman’s last vaginal examination was recorded as 4 cm, 60%, and –1. The nurse’s assessment of this report is the cervix is _____, with the presenting part 1 cm _____ the ischial spines.
a. 4 cm dilated and 60% effaced; above
b. effaced 4 cm and dilated 60%; above
c. effaced 4 cm and dilated 60%; below
d. 4 cm dilated and 60% effaced; below

ANS: A
Uterine contractions cause the cervix to efface (thin), measured in percentages, and dilate (open), described in centimeters (cm) from 1 to 10 (complete dilation). Station is the relationship of the presenting part to an imaginary line between the maternal ischial spines, measured in centimeters above (minus) or below (plus). At the level of the spines, the station is 0.

DIF: Cognitive Level: Application REF: 92-95 OBJ: 5
TOP: Powers: Uterine Contractions | Cervical Changes | Passenger: Station
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

22. A woman is admitted to the labor unit. The abdominal assessment reveals the following information: breech felt in fundus, fetal back on the right side of the woman’s abdomen, directed anteriorly with the small parts of the fetus on the left side and head firmly fixed in the pelvis. The presentation of the baby is:
a. LOA, engaged
b. LOA, not engaged
c. ROA, engaged
d. ROA, not engaged

ANS: C
R means the fetus’s back is on the right side of the mother’s abdomen. O means occiput, the fetus’s head is downward. A means the fetus is directed anteriorly. Engaged means the head is firmly fixed in the pelvis.

DIF: Cognitive Level: Application REF: 92-95 | Figures 6-3 and 6-4 | Box 6-1
OBJ: 10-11 TOP: Fetopelvic Relationship: Terminology
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

23. The time from the beginning of a contraction to its end is known as:
a. Duration
b. Interval
c. Intensity
d. Increment

ANS: A
The duration of a contraction is the time from the beginning until the end of the contraction.

DIF: Cognitive Level: Knowledge REF: 97-98 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

24. The approximate strength of a contraction is referred to as the:
a. Decrement
b. Interval
c. Intensity
d. Duration

ANS: C
The strength of a contraction is called its intensity.

DIF: Cognitive Level: Knowledge REF: 97-98 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

25. The period of increasing strength of a contraction is referred to as:
a. Increment
b. Interval
c. Intensity
d. Acme

ANS: A
The increment is the period of increasing strength of a contraction.

DIF: Cognitive Level: Knowledge REF: 96-97 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

26. A patient has been instructed to monitor the frequency of her contractions. Which statement by the patient indicates that the teaching was effective?
a. “I will count from the time one contraction starts until the beginning of the next contraction.”
b. “I will count from the time the contraction begins until the contraction ends.”
c. “I will count from the beginning of one contraction until the end of the next contraction.”
d. “I will count from the end of one contraction until the end of the next contraction.”

ANS: A
The frequency of contractions is the time from the beginning of one contraction until the beginning of the next contraction.

DIF: Cognitive Level: Application REF: 96-98 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

27. The period of greatest strength of a contraction is known as the:
a. Peak
b. Decrement
c. Increment
d. Intensity

ANS: A
The peak, or acme, is the period of greatest strength of a contraction.

DIF: Cognitive Level: Knowledge REF: 96-97 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

28. The patient in labor has a contraction interval of 45 seconds. Which action by the nurse is most appropriate?
a. Prepare for immediate delivery.
b. Turn the patient onto her right side.
c. Assist the patient in deep breathing exercises.
d. Report the finding to the registered nurse or physician.

ANS: D
The interval is the time of relaxation between contractions. A consistent interval shorter than 60 seconds may reduce fetal oxygen supply and should be reported to the registered nurse or physician.

DIF: Cognitive Level: Application REF: 97-98 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

29. The period of decreasing strength of a contraction is known as the:
a. Peak
b. Decrement
c. Increment
d. Intensity

ANS: B
The decrement is the period of decreasing strength of a contraction.

DIF: Cognitive Level: Knowledge REF: 96-97 | Figure 6-6
OBJ: 9 TOP: Characteristics of Uterine (Labor) Contractions
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

MULTIPLE RESPONSE

30. The process of labor involves both maternal and fetal adjustments in the interaction of which important variable(s)? (Select all that apply.)
a. Pelvis
b. Pressure
c. Passenger
d. Powers
e. Psyche

ANS: A, C, D, E
The “four Ps,” pelvis, passenger, powers, and psyche, are essential components of the labor and birth process, requiring both maternal and fetal adaptations.

DIF: Cognitive Level: Comprehension REF: 92 OBJ: 5
TOP: Major Variables in the Birth Process KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance

31. During the initial assessment of a woman admitted to the labor and delivery area, the nurse recognizes that the patient will be on bed rest. From the following assessment data, select the finding(s) that lead(s) her to this conclusion. (Select all that apply.)
a. Cervix dilated 5 cm
b. Cervical effacement 80%
c. Station –3
d. Uterine contraction frequency 3 to 5 minutes
e. Uterine contraction duration 45 to 60 seconds
f. SROM 1 hour before admission

ANS: A, C, F
A station of –3 indicates that the presenting part is not engaged (is above the ischial spines); an unengaged presenting part coupled with rupture of membranes increases the risk of umbilical cord prolapse. A cervix dilated to 5 cm, associated with a high presenting part and ruptured membranes, contributes to the risk of cord prolapse.

DIF: Cognitive Level: Analysis REF: 99 OBJ: 3
TOP: Spontaneous Rupture of Membranes
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

32. The clinic nurse instructs a group of pregnant women that which sign(s) may alert them to approaching labor? (Select all that apply.)
a. Lightening
b. Bloody show
c. Decreased energy level
d. Decreasing Braxton-Hicks contractions
e. Spontaneous rupture of membranes

ANS: A, B, E
Signs of approaching labor can include lightening, bloody show, energy spurt (“nesting behavior”), increased Braxton-Hicks contractions (false labor), and spontaneous rupture of membranes. (Cervical changes also occur, but a woman may not be aware of them.) Any of these signs may indicate that labor is likely to occur soon. With the exception of a rupture of membranes, it may not be necessary for the woman to consult her health care provider when these events happen.

DIF: Cognitive Level: Application REF: 98-99 OBJ: 4
TOP: Events Before Onset of Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance