Foundations Of Maternal Newborn and Women Health Nursing, 6th Edition by Sharon Smith Murray Test bank

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Foundations Of Maternal Newborn and Women Health Nursing, 6th Edition by Sharon Smith Murray Test bank

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Foundations Of Maternal Newborn and Womens Health Nursing, 6th Edition by Sharon Smith Murray Test bank

Chapter 02: The Nurses Role in Maternity and Womens Health Care

 

MULTIPLE CHOICE

 

  1. Which principle of teaching should the nurse use to ensure learning in a family situation?
a. Motivate the family with praise and positive feedback.
b. Learning is best accomplished with the lecture format.
c. Present complex subject material first while the family is alert and ready to learn.
d. Families should be taught using medical jargon so they will be able to understand the technical language used by physicians.

 

 

ANS:  A

Praise and positive feedback are particularly important when a family is trying to master a frustrating task such as breastfeeding. A lively discussion stimulates more learning than a straight lecture, which tends to inhibit questions. Learning is enhanced when the teaching is structured to present the simple tasks before the complex material. Even though a family may understand English fairly well, they may not understand the medical terminology or slang terms that are used.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18, 19

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which nursing intervention is an independent function of the nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the client perineal care
d. Providing wound care to a surgical incision

 

 

ANS:  C

Nurses are now responsible for various independent functions, including teaching, counseling, and intervening in nonmedical problems. Interventions initiated by the physician and carried out by the nurse are called dependent functions. Administrating oral analgesics is a dependent function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is a dependent function. Providing wound care is a dependent function; it is usually initiated by the physician through direct orders or protocol.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   24

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth should be made by the nurse?
a. Everything will be OK.
b. Dont worry about it. It will be over soon.
c. What concerns you most about a cesarean birth?
d. The physician will be in later and you can talk to him.

 

 

ANS:  C

The response, What concerns you most about a cesarean birth focuses on what the client is saying and asks for clarification, which is the most therapeutic response. The response, Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will be over soon will indicate that the clients feelings are not important. The response, The physician will be in later and you can talk to him does not allow the client to verbalize her feelings when she wishes to do that.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which action should the nurse take to evaluate the clients learning about performing infant care?
a. Demonstrate infant care procedures.
b. Allow the client to verbalize the procedure.
c. Routinely assess the infant for cleanliness.
d. Observe the client as she performs the procedure.

 

 

ANS:  D

The clients correct performance of the procedure under the nurses supervision is the best proof of her ability. Demonstration is an excellent teaching method, but not an evaluation method. During verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being used.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   21

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse is reviewing teaching and learning principles. Which situation is most conducive to learning?
a. An auditorium is being used as a classroom for 300 students.
b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
c. A class is composed of students of various ages and educational backgrounds.
d. An Asian nurse provides nutritional information to a group of pregnant Asian women.

 

 

ANS:  D

A clients culture influences the learning process; thus, a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the clients cultural beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher cannot see nonverbal cues from the students to ensure understanding. The ability to understand the language in which teaching is done determines how much the client learns. Clients for whom English is not their primary language may not understand idioms, nuances, slang terms, informed usage of words, or medical terms. The teacher should be fluent in the language of the student. Developmental levels and educational levels influence how a person learns best. For the teacher to present the information in the best way, the class should be at the same level.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Psychosocial Integrity

 

  1. Which is the step of the nursing process in which the nurse determines the appropriate interventions for the identified nursing diagnosis?
a. Planning
b. Evaluation
c. Assessment
d. Intervention

 

 

ANS:  A

The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   24

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which goal is most appropriate for the collaborative problem of wound infection?
a. The client will not exhibit further signs of infection.
b. Maintain the clients fluid intake at 1000 mL/8 hr.
c. The client will have a temperature of 98.6 F within 2 days.
d. Monitor the client to detect therapeutic response to antibiotic therapy.

 

 

ANS:  D

In a collaborative problem, the goal should be nurse-oriented and reflect the nursing interventions of monitoring or observing. Monitoring for complications such as further signs of infection is an independent nursing role. Intake and output is an independent nursing role. Monitoring a clients temperature is an independent nursing role.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which nursing intervention is correctly written?
a. Force fluids as necessary.
b. Observe interaction with the infant.
c. Encourage turning, coughing, and deep breathing.
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.

 

 

ANS:  D

Interventions might not be carried out if they are not detailed and specific. Force fluids is not specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is not detailed and specific. Observing interaction with the infant does not state how often this procedure should be done.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   25

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The client makes the statement: Im afraid to take the baby home tomorrow. Which response by the nurse would be the most therapeutic?
a. Youre afraid to take the baby home?
b. Dont you have a mother who can come and help?
c. You should read the literature I gave you before you leave.
d. I was scared when I took my first baby home, but everything worked out.

 

 

ANS:  A

This response uses reflection to show concern and open communication. The other choices are blocks to communication. Asking if the client has a mother who can come and help blocks further communication with the client. Telling the client to read the literature before leaving does not allow the client to express her feelings further. Sharing your feelings about your experience with a new baby blocks further communication with the client.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18, 19

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is writing an expected outcome for the nursing diagnosisacute pain related to trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of 10. Which is a correctly stated expected outcome for this problem?
a. Client will state that pain is a 2 on a scale of 10.
b. Client will have a reduction in pain after administration of the prescribed analgesic.
c. Client will state an absence of pain 1 hour after administration of the prescribed analgesic.
d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.

 

 

ANS:  D

The outcome should be client-centered, measurable, realistic, and attainable and have a time frame. Client stating that pain is now 2 on a scale of 10 lacks a time frame. Client having a reduction in pain after administration of the prescribed analgesic lacks a measurement. Client stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   25

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which nursing diagnosis should the nurse set as a priority for a laboring client?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical changes

 

 

ANS:  D

The nurse should determine which problem needs immediate attention. Risk for injury is the problem that has the priority at this time because it is a safety problem. Risk for anxiety, imbalanced nutrition, and altered family processes are not the priorities at this time.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   24, 25

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting.
b. Clinical nurse specialists provide primary care to obstetric clients.
c. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants.
d. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse.

 

 

ANS:  C

Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal intensive care unit, as needed. FNPs do not participate in childbirth care but can take care of uncomplicated pregnancies and postbirth care outside of the hospital setting. CNSs work in hospital settings but do not provide primary care services to clients. A CNM is an advanced practice nurse who receives additional certification in the specific area of midwifery.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   17

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Management of Care: Legal Rights and Responsibilities

 

  1. You are taking care of a couple postbirth who are very eager to learn about bathing techniques that they can use for their newborn. Which teaching technique could the nurse use to facilitate parents learning about giving a bath to their newborn infant?
a. Provide direct, step-by-step demonstration to each parent separately to foster individual retention and comprehension.
b. Present information to parents prior to discharge so that the information will be current.
c. Have each parent bathe the newborn each time the infant comes to the room and provide commentary after the skill repetition.
d. Demonstrate bathing techniques on the newborn infant with parents in attendance.

 

 

ANS:  D

Demonstration of bathing techniques is a form of role modeling that would enhance teaching and learning outcomes. Presenting the information at the time of discharge will not allow for identification of concerns and/or evaluation of whether the skill has been acquired. Although it may be advantageous to have each parent bathe their newborn, this action would not be advised in terms of time management and safety related to maintenance of core temperature.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   21

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. Which statement is true regarding the shortage of nurses in the United States?
a. There are a larger proportion of younger nurses in the workforce as compared with older nurses.
b. As a result of decreased RN-to-client ratios, there is a decrease in client mortality in the clinical setting.
c. Increased needs for baccalaureate nurses are not being met by current enrollment.
d. There are adequate classroom and clinical facilities for training RNs.

 

 

ANS:  C

According to an Institute of Medicine (IOM) report, by the year 2020, there will only be 50% of RNs with baccalaureate degrees. The required demand is at 80%. There are a larger proportion of older nurses in the workforce based on current research by the IOM. Increased RN-to-client ratios has resulted in decreased client mortality in the clinical setting. There are limitations of classroom and clinical facilities to train new nurses adequately.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   16

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification?
a. There is stratification of communication in a directed manner between nursing staff and administration.
b. There is increased job satisfaction of nurses, with a low staff turnover rate.
c. Physicians are certified in their respective specialty areas.
d. All nurses have baccalaureate degrees and certification in their clinical specialty area.

 

 

ANS:  B

Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center) in which hospitals apply based on designated criteria that consider nurse job satisfaction, staff patterns, strength, quality of nursing staff, and open communication. It is not based on physician status. Although the expectation is that at least 80% of the nurses will have baccalaureate degrees, most hospitals that achieve Magnet status have 50% of RNs at that level. Also, certification is not required for all nurses at this point. The expectation with Magnet status is that nurses will continue to expand their knowledge by earning additional degrees and certification.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   17

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. Which of the following indicates a nurses role as a researcher?
a. Reading peer-reviewed journal articles
b. Working as a member of the interdisciplinary team to provide client care
c. Helping client to obtain home care post-discharge from the hospital
d. Delegating tasks to unlicensed personnel to allow for more teaching time with clients

 

 

ANS:  A

A nurse in a researcher role should look to improve her or his knowledge base by reading and reviewing evidence-based practice information as found in peer-reviewed journals. Working as a member of the interdisciplinary team to provide client care indicates that the nurse is working as a collaborator. Helping the client to obtain home care post-discharge from the hospital indicates that the nurse is working as a client advocate. Delegating tasks to unlicensed personnel to allow for more teaching time with clients indicates that the nurse is working as a manager.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   21

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. A 16-year-old primipara has just completed her first prenatal visit with the health care provider. The nurse is preparing to teach her about nutrition during pregnancy. What must the nurse include in the patients teaching plan?
a. Provide her with pictures of dairy products.
b. Ask her, Are you ready to hear this information now?
c. Read directly from the pamphlet prepared for teen mothers.
d. Provide a comfortable and warm setting after she has put on her street clothes.

 

 

ANS:  D

The nurse must structure teaching for teens in a way that suits them best. For teaching to be most effective, the physical environment must be comfortable and distractions to learning must be kept at a minimum. Pictures, videos, and computer-based materials are more effective teaching tools for younger clients. Patients must have an attitude of readiness and openness for the teaching to be effective. However, if the environment is not conducive to learning, efforts for effective teaching will be minimized.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse states to the newly pregnant patient, Tell me how you feel about being pregnant. Which communication technique is the nurse using with this patient?
a. Clarifying
b. Paraphrasing
c. Reflection
d. Structuring

 

 

ANS:  A

The nurse is attempting to follow up and check the accuracy of the patients message. Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing comprehension of what the patient has said. Structuring takes place when the nurse has set guidelines or set priorities.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   19

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The pregnant woman tells the nurse, I think something may be wrong with my pregnancy. Which statement by the nurse demonstrates therapeutic communication?
a. Most women worry; I felt the same way when I was pregnant.
b. Tell me more about what concerns you about this pregnancy.
c. That is a very common concern, but your pregnancy will turn out just fine.
d. You should focus on taking care of yourself and not worry so much.

 

 

ANS:  B

Questioning is a therapeutic communication technique in which additional information is elicited by using open-ended questions. The remaining options are examples of three behaviors that block communicationinappropriate self-disclosure, providing false reassurance, and giving advice.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   18

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. The nurse is formulating a nursing care plan for a postpartum client. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply).
a. Using a standardized postpartum care plan
b. Determining priorities for each diagnosis written
c. Writing interventions from a nursing diagnosis book
d. Reflecting and suspending judgment when writing the care plan
e. Clustering data during the assessment process according to normal versus abnormal

 

 

ANS:  B, D, E

Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes reflective skepticism. Determining priorities, reflecting and suspending judgment, and clustering data are actions that indicate the use of critical thinking. Using a standardized care plan and writing interventions from a nursing diagnosis book do not show that reflection about the clients individual care is being done.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   27

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is teaching a group of nursing students about behaviors that can block or open lines of communication. Which behaviors open the lines of communication? (Select all that apply).
a. Sitting at the bedside
b. Leaning forward with arms relaxed
c. Acknowledging the clients comments or feelings
d. Self-disclosing about your personal birth experience
e. Holding a laptop computer in front of your body during an interview

 

 

ANS:  A, B, C

Behaviors that open the lines of communication can be described as attending behaviors, which convey the nurses interest and a sincere desire to understand. Acknowledging the clients comments or feelings is an attending behavior. Nonverbal behaviors are just as powerful as spoken words. The nurse should convey an open attitude, such as sitting at the bedside and leaning forward with arms relaxed while listening. Self-disclosing is inappropriate and closes lines of communication. Holding a laptop on your lap during the interview process is putting a barrier between the nurse and client.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Psychosocial Integrity

 

MATCHING

 

Match each term with the correct definition.

a. Calling attention to differences or inconsistencies in statements
b. Using nonverbal responses or succinct comments to encourage the person to continue
c. Restating in words other than those used by the woman what she seems to express; a form of clarification

 

 

  1. Directing

 

  1. Pinpointing

 

  1. Paraphrasing

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   19                  OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Pinpointing is calling attention to differences or inconsistencies in statements. Directing is using nonverbal responses or succinct comments to encourage the person to continue. Paraphrasing is restating in words other than those used by the woman what she seems to express; it is a form of clarification.

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   19                  OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Pinpointing is calling attention to differences or inconsistencies in statements. Directing is using nonverbal responses or succinct comments to encourage the person to continue. Paraphrasing is restating in words other than those used by the woman what she seems to express; it is a form of clarification.

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   19                  OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Pinpointing is calling attention to differences or inconsistencies in statements. Directing is using nonverbal responses or succinct comments to encourage the person to continue. Paraphrasing is restating in words other than those used by the woman what she seems to express; it is a form of clarification.

Chapter 12: Processes of Birth

 

MULTIPLE CHOICE

 

  1. The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that hes doing now, he could tell her when the contractions are:
a. 2 minutes apart.
b. at their acme.
c. at their increment.
d. at their decrement.

 

 

ANS:  B

When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   196, 197

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction?
a. Is not significantly affected
b. Increases as blood pressure decreases
c. Diminishes as the spiral arteries are compressed
d. Continues except when placental functions are reduced

 

 

ANS:  C

During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   199

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions?
a. Vital signs taken during contractions are not accurate.
b. During a contraction, assessing fetal heart rate is the priority.
c. Maternal blood flow to the heart is reduced during contractions.
d. Maternal circulating blood volume increases temporarily during contractions.

 

 

ANS:  D

During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   198

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Uncontrolled maternal hyperventilation during labor results in:
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.

 

 

ANS:  D

Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
a. Extension
b. Engagement
c. Internal rotation
d. External rotation

 

 

ANS:  B

Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   209

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by:
a. promoting blood flow to the cervix.
b. contracting the lower uterine segment.
c. enlarging the internal size of the uterus.
d. pulling the cervix over the fetus and amniotic sac.

 

 

ANS:  D

Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   198

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have:
a. a higher hematocrit.
b. increased leukocytes.
c. increased blood volume.
d. a lower fibrinogen level.

 

 

ANS:  C

Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions?
a. Assess the strongest intensity of each contraction.
b. Assess uterine relaxation between two contractions.
c. Assess from the beginning to the end of each contraction.
d. Assess from the beginning of one contraction to the beginning of the next.

 

 

ANS:  C

Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   196, 197

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which event is the best indicator of true labor?
a. Bloody show
b. Cervical dilation and effacement
c. Fetal descent into the pelvic inlet
d. Uterine contractions every 7 minutes

 

 

ANS:  B

The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?
a. Station
b. Flexion
c. Descent
d. Engagement

 

 

ANS:  B

The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   209

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates:
a. lightening.
b. breech presentation.
c. urinary tract infection.
d. onset of Braxton-Hicks contractions.

 

 

ANS:  A

As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   207

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long?
a. 50 minutes
b.  hours
c. 6 to 7 hours
d. 8 to 10 hours

 

 

ANS:  D

The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 minutes for a nullipara. The transition phase lasts  hours for a nullipara. A multiparas active phase of labor is 6 to 7 hours.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   208

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client?
a. This results from molding.
b. This results from lightening.
c. This results from the fetal lie.
d. This results from the fetal presentation.

 

 

ANS:  A

The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   201

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A client whose cervix is dilated to 5 cm is considered to be in which phase of labor?
a. Latent phase
b. Active phase
c. Second stage
d. Third stage

 

 

ANS:  B

The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   212

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase?
a. The client is sociable and excited.
b. The client is requesting pain medication.
c. The client begins to experience the urge to push.
d. The client experiences loss of control and irritability.

 

 

ANS:  B

During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   212

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
a. The acme
b. The interval
c. The increment
d. The decrement

 

 

ANS:  A

The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   196, 197

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with:
a. more rapid labor.
b. a high risk of infection.
c. maternal perineal trauma.
d. umbilical cord compression.

 

 

ANS:  D

The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   202, 203

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The primary difference between the labor of a nullipara and that of a multipara is:
a. total duration of labor.
b. level of pain experienced.
c. amount of cervical dilation.
d. sequence of labor mechanisms.

 

 

ANS:  A

Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   214

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. Which maternal factor may inhibit fetal descent?
a. A full bladder
b. Decreased peristalsis
c. Rupture of membranes
d. Reduction in internal uterine size

 

 

ANS:  A

A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which assessment finding would cause a concern for a client who had delivered vaginally?
a. Estimated blood loss (EBL) of 500 mL during the birth process
b. White blood cell count of 28,000 mm3 postbirth
c. Client complains of fingers tingling
d. Client complains of thirst

 

 

ANS:  C

A clients complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   198

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity/Reduction of Risk Potential

 

  1. Which clinical findings would be considered to be normal for a preterm fetus during the labor period?
a. Baseline tachycardia
b. Baseline bradycardia
c. Fetal anemia
d. Acidosis

 

 

ANS:  A

Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation

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