Maternity And Women Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

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Maternity And Women Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

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WITH ANSWERS
Maternity And Womens Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

Chapter 02: Community Care: The Family and Culture

Lowdermilk: Maternity & Womens Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. A married couple lives in a single-family house with their newborn son and the husbands daughter from a previous marriage. Based on this information, what family form best describes this family?
a. Married-blended family
b. Extended family
c. Nuclear family
d. Same-sex family

 

 

ANS:  A

Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join to create a new household. Members of an extended family are kin or family members related by blood, such as grandparents, aunts, and uncles. A nuclear family is a traditional family with male and female partners along with the children resulting from that union. A same-sex family is a family with homosexual partners who cohabit with or without children.

 

DIF:    Cognitive Level: Remember           REF:   p. 19

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which key factors play the most powerful role in the behaviors of individuals and families?
a. Rituals and customs
b. Beliefs and values
c. Boundaries and channels
d. Socialization processes

 

 

ANS:  B

Beliefs and values are the most prevalent factors in the decision-making and problem-solving behaviors of individuals and families. This prevalence is particularly true during times of stress and illness. Although culture may play a part in the decision-making process of a family, ultimately, values and beliefs dictate the course of action taken by family members. Boundaries and channels affect the relationship between the family members and the health care team, not the decisions within the family. Socialization processes may help families with interactions within the community, but they are not the criteria used for decision making within the family.

 

DIF:    Cognitive Level: Understand          REF:   pp. 21-22       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Using the family stress theory as an interventional approach for working with families experiencing parenting challenges, the nurse can assist the family in selecting and altering internal context factors. Which statement best describes the components of an internal context?
a. Biologic and genetic makeup
b. Maturation of family members
c. Familys perception of the event
d. Prevailing cultural beliefs of society

 

 

ANS:  C

The family stress theory is concerned with the familys reaction to stressful events. Internal context factors include elements that a family can control such as psychologic defenses, family structure, and philosophic beliefs and values. The family stress theory focuses on ways that families react to stressful events. Maturation of family members is more relevant to the family life-cycle theory. The family stress theory focuses on internal elements that a family might be able to alter.

 

DIF:    Cognitive Level: Understand          REF:   p. 21              TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is developing a plan of care for a Hispanic client who just delivered a newborn. Which cultural variation is most important to include in the care plan?
a. Breastfeeding is encouraged immediately after birth.
b. Male infants are typically circumcised.
c. Maternal grandmother participates in the care of the mother and her infant.
d. Bathing is encouraged immediately after delivery.

 

 

ANS:  C

In the Hispanic family, the expectant mother is strongly influenced by her mother or mother-in-law. Breastfeeding is often delayed until the third postpartum day. Hispanic male infants are not usually circumcised. Bathing after delivery is most often delayed.

 

DIF:    Cognitive Level: Apply                  REF:   p. 26              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which health care service represents a primary level of prevention?
a. Immunizations
b. Breast self-examination (BSE)
c. Home care for high-risk pregnancies
d. Blood pressure screening

 

 

ANS:  A

Primary prevention involves health promotion and disease prevention activities to reduce the occurrence of illness and enhance the general health and quality of life. This level of care includes, for example, immunizations, using infant car seats, and providing health education to prevent tobacco use. BSE is an example of secondary prevention that involves early detection of health problems. Home care for a high-risk pregnancy is an example of tertiary prevention. This level of care follows the occurrence of a defect or disability. Blood pressure screening is an example of secondary prevention and is a screening tool for early detection of a health care problem.

 

DIF:    Cognitive Level: Understand          REF:   p. 34

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the primary difference between hospital care and home health care?
a. Home care is routinely and continuously delivered by professional staff.
b. Home care is delivered on an intermittent basis by professional staff.
c. Home care is delivered for emergency conditions.
d. Home care is not available 24 hours a day.

 

 

ANS:  B

Home care is generally delivered on an intermittent basis by professional staff members. The primary difference between health care in a hospital and home care is the absence of the continuous presence of professional health care providers in a clients home. In a true emergency, the client should be directed to call 9-1-1 or to report to the nearest hospitals emergency department. Generally, home health care entails intermittent care by a professional who visits the clients home for a particular reason and provides on-site care for periods shorter than 4 hours at a time.

 

DIF:    Cognitive Level: Understand          REF:   pp. 34-35

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. To provide culturally competent care to an Asian-American family, which question should the nurse include during the assessment interview?
a. Do you prefer hot or cold beverages?
b. Do you want some milk to drink?
c. Do you want music playing while you are in labor?
d. Do you have a name selected for the baby?

 

 

ANS:  A

Asian-Americans often prefer warm beverages. Milk is usually excluded from the diet of this population. Asian-American women typically labor in a quiet environment. Delaying naming the child is not uncommon for Asian-American families.

 

DIF:    Cognitive Level: Apply                  REF:   p. 27

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. The womans family members are present when the nurse arrives for a postpartum and newborn visit. What should the nurse do?
a. Observe the family members interactions with the newborn and one another.
b. Ask the woman to meet with her and the baby alone.
c. Perform a brief assessment on all family members who are present.
d. Reschedule the visit for another time so that the mother and infant can be privately assessed.

 

 

ANS:  A

The nurse should introduce her or himself to the client and to the other family members who are present. Family members in the home may be providing care and assistance to the mother and infant. However, this care may not be based on sound health practices. Nurses should take the opportunity to dispel myths while family members are present. The responsibility of the home care maternal-child nurse is to provide care to the new postpartum mother and to her infant, not to all family members. The nurse can politely ask about the other people in the home and their relationships with the mother. Unless an indication is given that the woman would prefer privacy, the visit may continue.

 

DIF:    Cognitive Level: Analyze               REF:   p. 35

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What is a limitation of a home postpartum visit?
a. Distractions limit the nurses ability to teach.
b. Identified problems cannot be resolved in the home setting.
c. Necessary items for infant care are not available.
d. Home visits to different families may require the nurse to travel a great distance.

 

 

ANS:  D

One limitation of home health visits is the distance the nurse must travel between clients. Driving directions should be obtained by telephone before the visit. The home care nurse is accustomed to distractions but may request that the television be turned off so that attention can be focused on the client and her family. Problems cannot always be resolved; however, appropriate referrals may be arranged by the nurse. The nurse is required to bring any necessary equipment, such as a thermometer, baby scale, or laptop computer, for documentation.

 

DIF:    Cognitive Level: Understand          REF:   p. 35              TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. During the childbearing experience, which behavior might the nurse expect from an African-American client?
a. Seeking prenatal care early in her pregnancy
b. Avoiding self-treatment of pregnancy-related discomfort
c. Requesting liver in the postpartum period to prevent anemia
d. Arriving at the hospital in advanced labor

 

 

ANS:  D

African-American women often arrive at the hospital in far-advanced labor and may view pregnancy as a state of wellness, which is often the reason for the delay in seeking prenatal care. African-American women practice many self-treatment options for various discomforts of pregnancy. African-American women may also request liver in the postpartum period, which is based on a belief that liver has a higher blood content.

 

DIF:    Cognitive Level: Understand          REF:   p. 26

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which resource best describes a health care service representing the tertiary level of prevention?
a. Stress management seminars
b. Childbirth education classes for single parents
c. BSE pamphlet and teaching
d. Premenstrual syndrome (PMS) support group

 

 

ANS:  D

A PMS support group is an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., PMS). Stress management seminars are a primary prevention technique for preventing health care issues associated with stress. Childbirth education is a form of primary prevention. BSE information is a form of secondary prevention, which is aimed toward early detection of health problems.

 

DIF:    Cognitive Level: Understand          REF:   p. 28

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. When the services of an interpreter are needed, which is the most important factor for the nurse to consider?
a. Using a family member who is fluent in both languages
b. Using an interpreter who is certified, and documenting the persons name in the nursing notes
c. Directing questions only to the interpreter
d. Using an interpreter only in an emergency

 

 

ANS:  B

Using a certified interpreter ensures that the standards of care are met and that the information exchanged is reliable and unaltered. The name of the interpreter should be documented for legal purposes. Asking a family member to interpret may not be appropriate, although many health care personnel must adopt this approach in an emergency. Furthermore, most states require that certified interpreters be used when possible. When using an interpreter, the nurse should direct questions to the client. The interpreter is simply a means by which the nurse communicates with the client. Every attempt should be made to contact an interpreter whenever one is needed. During an emergency, health care workers often rely on information interpreted by family members. This information may be private and should be protected under the rules established by the Health Insurance Portability and Accountability Act (HIPAA). Furthermore, family members may skew information or may not be able to interpret the exact information the nurse is trying to obtain.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 24, 25

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which traditional family structure is decreasing in numbers and attributable to societal changes?
a. Extended family
b. Binuclear family
c. Nuclear family
d. Blended family

 

 

ANS:  C

The nuclear family has long represented the traditional American family in which husband, wife, and children live as an independent unit. As a result of rapid changes in society, this number is steadily decreasing as other family configurations are socially recognized. Extended families involve additional blood relatives other than the parents. A binuclear family involves two households. A blended family is reconstructed after divorce and involves the merger of two families.

 

DIF:    Cognitive Level: Understand          REF:   p. 18

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement regarding the Family Systems Theory is inaccurate?
a. Family system is part of a larger suprasystem.
b. Family, as a whole, is equal to the sum of the individual members.
c. Changes in one family member affect all family members.
d. Family is able to create a balance between change and stability.

 

 

ANS:  B

A family, as a whole, is greater than the sum of its individual members. The other statements are accurate and can be attributed to the Family Systems Theory.

 

DIF:    Cognitive Level: Understand          REF:   p. 21

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which pictorial tool can assist the nurse in assessing the aspects of family life related to health care?
a. Genogram
b. Ecomap
c. Life-cycle model
d. Human development wheel

 

 

ANS:  A

A genogram depicts the relationships of the family members over generations. An ecomap is a graphic portrayal of the social relationships of the woman and her family. The life-cycle model, in no way, illustrates a family genogram; rather, it focuses on the stages that a person reaches throughout life. The human development wheel describes various stages of growth and development rather than the family members relationships to each other.

 

DIF:    Cognitive Level: Remember           REF:   pp. 20-21

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. When attempting to communicate with a client who speaks a different language, which action is the most appropriate?
a. Promptly and positively respond to project authority.
b. Never use a family member as an interpreter.
c. Talk to the interpreter to avoid confusing the client.
d. Provide as much privacy as possible.

 

 

ANS:  D

Providing privacy creates an atmosphere of respect and puts the client at ease. The nurse should not rush to judgment and should ensure she or he clearly understands the clients message. In crisis situations, the nurse may need to use a family member or neighbor as a translator. The nurse should speak directly to the client to create an atmosphere of respect.

 

DIF:    Cognitive Level: Apply                  REF:   p. 24

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The secondary level of prevention is best illustrated by which example?
a. Approved infant car seats
b. BSE
c. Immunizations
d. Support groups for parents of children with Down syndrome

 

 

ANS:  B

Infant car seats are an example of primary prevention. BSE is an example of the secondary level of prevention, which includes health-screening measures for early detection of health problems. Immunizations are an example of the primary level of prevention. Support groups are an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., Down syndrome).

 

DIF:    Cognitive Level: Understand          REF:   p. 28              TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which key point is important for the nurse to understand regarding the perinatal continuum of care?
a. Begins with conception and ends with the birth
b. Begins with family planning and continues until the infant is 1 year old
c. Begins with prenatal care and continues until the newborn is 24 weeks old
d. Refers to home care only

 

 

ANS:  B

The perinatal continuum of care begins with family planning and continues until the infant is 1 year old. It takes place both at home and in health care facilities. The perinatal continuum does not end with the birth. The perinatal continuum begins before conception and continues after the birth. Home care is one delivery component; health care facilities are another.

 

DIF:    Cognitive Level: Remember           REF:   p. 17              TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What information should the nurse be aware of regarding telephonic nursing care such as warm lines?
a. Were developed as a reaction to impersonal telephonic nursing care
b. Were set up to take complaints concerning health maintenance organizations (HMOs)
c. Are the second option when 9-1-1 hotlines are busy
d. Refer to community service telephone lines designed to provide new parents with encouragement and basic information

 

 

ANS:  D

Warm lines are one aspect of telephonic nursing care specifically designed to provide new parents with encouragement and basic information. Warm lines and similar services sometimes are set up by HMOs to provide new parents with encouragement and basic information. The name, warm lines, may have been suggested by the term hotlines, but these are not emergency numbers but are designed to provide new parents with encouragement and basic information.

 

DIF:    Cognitive Level: Remember           REF:   p. 34

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When weighing the advantages and disadvantages of planning home care for perinatal services, what information should the nurse use in making the decision?
a. Home care for perinatal services is more dangerous for vulnerable neonates at risk of acquiring an infection from the nurse.
b. Home care for perinatal services is more cost-effective for the nurse than office visits.
c. Home care for perinatal services allows the nurse to interact with and include family members in teaching.
d. Home care for perinatal services is made possible by the ready supply of nurses with expertise in maternity care.

 

 

ANS:  C

Treating the whole family is an advantage of home care. Forcing neonates out in inclement weather and in public is more risky. Office visits are more cost-effective for the providers such as nurses because less travel time is involved. Unfortunately, home care options are limited by the lack of nurses with expertise in maternity care.

 

DIF:    Cognitive Level: Apply                  REF:   p. 35

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. In what form do families tend to be the most socially vulnerable?
a. Married-blended family
b. Extended family
c. Nuclear family
d. Single-parent family

 

 

ANS:  D

The single-parent family tends to be economically and socially vulnerable, creating an unstable and deprived environment for the growth potential of children. The married-blended family, the extended family, and the nuclear family are not the most socially vulnerable.

 

DIF:    Cognitive Level: Understand          REF:   p. 19              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. While working in the prenatal clinic, nurses care for a very diverse group of clients. Which cultural factor related to health is most likely to drive acceptance of planned interventions?
a. Educational achievement
b. Income level
c. Subcultural group
d. Individual beliefs

 

 

ANS:  D

The clients beliefs are ultimately the key to the acceptance of health care interventions. However, these beliefs may be influenced by factors such as educational level, income level, and ethnic background. Educational achievement, income level, and being part of a subcultural group all are important factors. However, the nurse must understand that a womans concerns from her own point of view will have the most influence on her compliance and acceptance of health care interventions.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 21-22       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A clients household consists of her husband, his mother, and another child. To which family configuration does this client belong?
a. Multigenerational family
b. Single-parent family
c. Married-blended family
d. Nuclear family

 

 

ANS:  A

A multigenerational family includes three or more generations living together. Both parents and a grandparent are living in this extended family. Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults. Married-blended families refer to those who are reconstructed after divorce. A nuclear family comprises male and female partners and their children living together as an independent unit.

 

DIF:    Cognitive Level: Apply                  REF:   p. 19

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which term is an accurate description of the process by which people retain some of their own culture while adopting the practices of the dominant society?
a. Acculturation
b. Assimilation
c. Ethnocentrism
d. Cultural relativism

 

 

ANS:  A

Acculturation is the process by which people retain some of their own culture while adopting the practices of the dominant society. This process takes place over the course of generations. Assimilation is a loss of cultural identity. Ethnocentrism is the belief in the superiority of ones own culture over the cultures of others. Cultural relativism recognizes the roles of different cultures.

 

DIF:    Cognitive Level: Understand          REF:   pp. 22-23       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. In which culture is the father more likely to be expected to participate in the labor and delivery?
a. Asian-American
b. African-American
c. European-American
d. Hispanic

 

 

ANS:  C

European-Americans expect the father to take a more active role in the labor and delivery of a newborn than the other cultures.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement about the development of cultural competence is inaccurate?
a. Local health care workers and community advocates can help extend health care to underserved populations.
b. Nursing care is delivered in the context of the clients culture but not in the context of the nurses culture.
c. Nurses must develop an awareness of and a sensitivity to various cultures.
d. Cultures economic, religious, and political structures influence practices that affect childbearing.

 

 

ANS:  B

Although the cultural context of the nurse affects the delivery of nursing care and is very important, the work of local health care workers and community advocates, developing sensitivity to various cultures, and the impact of economic, religious, and political structures are all parts of cultural competence.

 

DIF:    Cognitive Level: Understand          REF:   pp. 27-28       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement accurately describes the walking survey as a data collection tool?
a. The walking survey determines how much exercise an expectant mother has been getting, to help her make health care decisions.
b. The walking survey usually takes place on the maternity ward but can be expanded to other areas of the hospital.
c. The walking survey is a method of observing the resources and health-related environment of the community.
d. The walking survey is performed by government census takers as part of their canvas.

 

 

ANS:  C

The walking survey is a valuable tool for the nurses in the community and has nothing to do with exercise. It is an observational method used to assess the health environment of the community. A walking survey takes place in the community, not the maternity ward, and is not part of the census; it is conducted by nurses in the community.

 

DIF:    Cognitive Level: Remember           REF:   p. 30

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A Native-American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for bottle feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of what?
a. Delayed attachment
b. Embarrassment
c. Disappointment in the sex of the baby
d. Belief that babies should not be fed colostrum

 

 

ANS:  D

Native Americans often use cradle boards and often avoid handling their newborn. They also believe that the infant should not be fed colostrum. Delayed attachment is a developmental concern, not a cultural belief. Embarrassment is not likely the cause for a delay in the initiation of breastfeeding and should be explored further by the nurse. The mother may voice her disappointment that the infant is a girl; however, this would rarely cause her to delay breastfeeding and would exhibit itself in other ways.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. While completing an assessment of a homeless woman, the nurse should be aware of which of the following ailments this client is at a higher risk to develop? (Select all that apply.)
a. Infectious diseases
b. Chronic illness
c. Anemia
d. Hyperthermia
e. Substance abuse

 

 

ANS:  A, B, C, E

Poor living conditions contribute to higher rates of infectious disease. Many homeless individuals engage in sexual favors, which may expose them to sexually transmitted infections (STIs). Poor nutrition can lead to anemia. Lifestyle factors also contribute to chronic illness. Exposure to cold temperatures and harsh environmental surroundings may lead to hypothermia. Many homeless people turn to alcohol and other substances as coping mechanisms.

 

DIF:    Cognitive Level: Analyze               REF:   pp. 32-33

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe and Effective Care Environment

 

Chapter 16: Labor and Birth Processes

Lowdermilk: Maternity & Womens Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. A new mother asks the nurse when the soft spot on her sons head will go away. What is the nurses best response, based upon her understanding of when the anterior frontal closes?
a. 2 months
b. 8 months
c. 12 months
d. 18 months

 

 

ANS:  D

The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. The posterior fontanel closes at 6 to 8 weeks. The remaining three options are too early for the anterior fontanel to close.

 

DIF:    Cognitive Level: Understand          REF:   p. 367

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is performing an initial assessment of a client in labor. What is the appropriate terminology for the relationship of the fetal body parts to one another?
a. Lie
b. Presentation
c. Attitude
d. Position

 

 

ANS:  C

Attitude is the relationship of the fetal body parts to one another. Lie is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relationship of the presenting part of the fetus to the four quadrants of the mothers pelvis.

 

DIF:    Cognitive Level: Remember           REF:   p. 369

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When assessing the fetus using Leopolds maneuvers, the nurse feels a round, firm, and movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mothers right side close to midline. What is the position of the fetus?
a. ROA
b. LSP
c. RSA
d. LOA

 

 

ANS:  C

Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or the left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relationship to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is anteriorly positioned in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is anteriorly positioned in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is posteriorly positioned in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be anteriorly positioned in the left side of the pelvis with the occiput as the presenting part.

 

DIF:    Cognitive Level: Apply                  REF:   p. 370

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement by the client would lead the nurse to believe that labor has been established?
a. I passed some thick, pink mucus when I urinated this morning.
b. My bag of waters just broke.
c. The contractions in my uterus are getting stronger and closer together.
d. My baby dropped, and I have to urinate more frequently now.

 

 

ANS:  C

Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Although the loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor; however, it is not an indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor but is not the indicator of true labor.

 

DIF:    Cognitive Level: Understand          REF:   p. 376

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse has received a report regarding a client in labor. The womans last vaginal examination was recorded as 3 cm, 30%, and 2. What is the nurses interpretation of this assessment?
a. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
b. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
c. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
d. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

 

 

ANS:  B

The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. The first interpretation of this vaginal examination is incorrect; the cervix is dilated 3 cm and is 30% effaced. However, the presenting part is correct at 2 cm above the ischial spines. The remaining two interpretations of this vaginal examination are incorrect. Although the dilation and effacement are correct at 3 cm and 30%, the presenting part is actually 2 cm above the ischial spines.

 

DIF:    Cognitive Level: Comprehend        REF:   p. 370 | pp. 373-374

TOP:   Nursing Process: Assessment | Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant woman is at 38 weeks of gestation. She wants to know whether there are any signs that labor is getting close to starting. Which finding is an indication that labor may begin soon?
a. Weight gain of 1.5 to 2 kg (3 to 4 lb)
b. Increase in fundal height
c. Urinary retention
d. Surge of energy

 

 

ANS:  D

Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, as a result of water loss caused by electrolyte shifts that, in turn, are caused by changes in the estrogen and progesterone levels. When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor.

 

DIF:    Cognitive Level: Understand          REF:   p. 376            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which stage of labor varies the most in length?
a. First
b. Second
c. Third
d. Fourth

 

 

ANS:  A

The first stage of labor is considered to last from the onset of regular uterine contractions to the full dilation of the cervix. The first stage is significantly longer than the second and third stages combined. In a first-time pregnancy, the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts approximately 2 hours after the delivery of the placenta.

 

DIF:    Cognitive Level: Remember           REF:   p. 376            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse expects which maternal cardiovascular finding during labor?
a. Increased cardiac output
b. Decreased pulse rate
c. Decreased white blood cell (WBC) count
d. Decreased blood pressure

 

 

ANS:  A

During each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system, which increases cardiac output by approximately 10% to 15% during the first stage of labor and by approximately 30% to 50% in the second stage of labor. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by approximately 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg.

 

DIF:    Cognitive Level: Understand          REF:   p. 379            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the correct term describing the slight overlapping of cranial bones or shaping of the fetal head during labor?
a. Lightening
b. Molding
c. Ferguson reflex
d. Valsalva maneuver

 

 

ANS:  B

Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mothers sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after the stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor.

 

DIF:    Cognitive Level: Remember           REF:   p. 367

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which presentation is accurately described in terms of both the resenting part and the frequency of occurrence?
a. Cephalic: occiput, at least 96%
b. Breech: sacrum, 10% to 15%
c. Shoulder: scapula, 10% to 15%
d. Cephalic: cranial, 80% to 85%

 

 

ANS:  A

In cephalic presentations (head first), the presenting part is the occiput; this presentation occurs in 96% of births. In a breech birth, the sacrum emerges first; this presentation occurs in approximately 3% of births. In shoulder presentations, the scapula emerges first; this presentation occurs in only 1% of births. In a cephalic presentation, the part of the head or cranium that emerges first is the occiput; cephalic presentations occur in 96% of births.

 

DIF:    Cognitive Level: Understand          REF:   p. 368            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A labor and delivery nurse should be cognizant of which information regarding how the fetus moves through the birth canal?
a. Fetal attitude describes the angle at which the fetus exits the uterus.
b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother.
c. Normal attitude of the fetus is called general flexion.
d. Transverse lie is preferred for vaginal birth.

 

 

ANS:  C

The normal attitude of the fetus is called general flexion. The fetal attitude is the relationship of the fetal body parts to each one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie, the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie.

 

DIF:    Cognitive Level: Understand          REF:   p. 369            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A womans position is an important component of the labor progress. Which guidance is important for the nurse to provide to the laboring client?
a. The supine position, which is commonly used in the United States, increases blood flow.
b. The laboring client positioned on her hands and knees (all fours position) is hard on the womans back.
c. Frequent changes in position help relieve fatigue and increase the comfort of the laboring client.
d. In a sitting or squatting position, abdominal muscles of the laboring client will have to work harder.

 

 

ANS:  C

Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The all fours position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions.

 

DIF:    Cognitive Level: Apply                  REF:   p. 375

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Certain changes stimulate chemoreceptors in the aorta and carotid bodies to prepare the fetus for initiating respirations immediately after birth. Which change in fetal physiologic activity is not part of this process?
a. Fetal lung fluid is cleared from the air passages during labor and vaginal birth.
b. Fetal partial pressure of oxygen (PO2) decreases.
c. Fetal partial pressure of carbon dioxide in arterial blood (PaCO2) increases.
d. Fetal respiratory movements increase during labor.

 

 

ANS:  D

Fetal respiratory movements actually decrease during labor. Fetal lung fluid is cleared from the air passages during labor and vaginal birth. Fetal PO2 decreases, and fetal PaCO2 increases.

 

DIF:    Cognitive Level: Understand          REF:   p. 379

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which description of the four stages of labor is correct for both the definition and the duration?
a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours
b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours
c. Third stage: active pushing to birth; 20 minutes (multiparous woman), 50 minutes (nulliparous woman)
d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

 

 

ANS:  A

Full dilation may occur in less than 1 hour, but in first-time pregnancies full dilation can take up to 20 hours. The second stage of labor extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage of labor extends from birth to the expulsion of the placenta and usually takes a few minutes. The fourth stage begins after the expulsion of the placenta and lasts until homeostasis is reestablished (approximately 2 hours).

 

DIF:    Cognitive Level: Understand          REF:   pp. 376-377   TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Nurses should be cognizant of what regarding the mechanism of labor?
a. Seven critical movements must progress in a more or less orderly sequence.
b. Asynclitism is sometimes achieved by means of the Leopolds maneuver.
c. Effects of the forces determining descent are modified by the shape of the womans pelvis and the size of the fetal head.
d. At birth, the baby is said to achieve restitution; that is, a return to the C-shape of the womb.

 

 

ANS:  C

The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor simultaneously occur in combinations, not in precise sequences. Asynclitism is the deflection of the babys head; the Leopolds maneuver is a means of judging descent by palpating the mothers abdomen. Restitution is the rotation of the babys head after the infant is born.

 

DIF:    Cognitive Level: Understand          REF:   p. 377

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement related to fetal positioning during labor is correct and important for the nurse to understand?
a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal.
b. Birth is imminent when the presenting part is at +4 to +5 cm below the spine.
c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter.
d. Engagement is the term used to describe the beginning of labor.

 

 

ANS:  B

The station of the presenting part should be noted at the beginning of labor to determine the rate of descent. Position is the relationship of the presenting part of the fetus to the four quadrants of the mothers pelvis; station is the measure of degree of descent. The largest diameter is usually the biparietal diameter. The suboccipitobregmatic diameter is the smal

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