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Terms in this set (29)1. The nurse measures the frequency of a laboring woman's contractions by noting: a. how long the patient states the contractions last. ANS: D DIF: Cognitive Level: Comprehension REF: p. 120 OBJ: 7 2. The relaxation phase between contractions is important because the: a. laboring woman needs to rest. ANS: C 3. The nurse recognizes the contraction duration and interval that could result in fetal compromise is: a. duration shorter than 30 seconds, interval longer than 75 seconds. ANS: C DIF: Cognitive Level: Analysis REF: p. 121, Safety Alert 4. Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. This presentation is referred to as: a. vertex. ANS: A DIF: Cognitive Level: Application REF: p. 124 OBJ: 7 5. When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates: a. fetal distress. ANS: A DIF: Cognitive Level: Analysis REF: p. 137 OBJ: 7 6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. The nurse would record this presentation as: a. complete breech. ANS: B DIF: Cognitive Level: Application REF: p. 124, Figure 6-7 7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by: a. contractions that are relieved by walking. ANS:
D DIF: Cognitive Level: Application REF: p. 127 OBJ: 8 8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. The nurse's most informative response would be that the woman should come when she: a. feels increased fetal movement. ANS: C DIF: Cognitive Level: Application REF: p. 127 OBJ: 6 9. The nurse caring for a woman in the first stage of labor reminds the patient that contractions during this stage of labor: a. get the infant positioned for delivery. ANS: C DIF: Cognitive Level: Comprehension REF: p. 145, Table 6-6 10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, the nurse assesses the most likely explanation for the woman's change in behavior is that: a. labor has progressed to the transition phase. ANS: A DIF: Cognitive Level: Analysis REF: p. 145, Table 6-6 11. The nurse explains that the function of contractions during the second stage of labor is to: a. align the infant into the proper position for delivery. ANS: C DIF: Cognitive Level: Knowledge REF: p. 145, Table 6-6 12. The nurse explains that the third stage of labor ends with: a. full cervical dilation. ANS: B DIF: Cognitive Level: Knowledge REF: p. 146, Table 6-6 13. During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may: a. interfere with cervical dilation. ANS:
D DIF: Cognitive Level: Application REF: p. 146, Table 6-6 14. When the nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" The nurse should: a. go find the physician. ANS: B DIF: Cognitive Level: Application REF: p. 129 OBJ: 6 15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of: a. a well-oxygenated fetus. ANS: A DIF: Cognitive Level: Analysis REF: p. 134 OBJ: 7 16. The nurse would coach the laboring woman with a fully dilated cervix to push by saying: a. "At the beginning of a contraction, hold your
breath and push for 10 seconds." ANS: D DIF: Cognitive Level: Application REF: p. 142 OBJ: 7 17. The most important nursing activity during the fourth stage of labor is to: a. monitor the frequency and intensity of contractions. ANS: C 18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. The nurse should: a. check the fundus for position
and firmness. ANS: A DIF: Cognitive Level: Application REF: p. 147 OBJ: 7 19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurse's initial action is to: a. stop the oxytocin infusion. ANS: C DIF: Cognitive Level: Analysis REF: p. 139 OBJ: 7 20. To relieve perineal bruising and edema following delivery the nurse should: a. place an ice pack on the area for 12 hours. ANS: A DIF: Cognitive Level: Comprehension REF: p. 150
OBJ: 7 21. At 1 and 5 minutes of life, a newborn's Apgar score is 9. The nurse understands that a score of 9 indicates this newborn: a. will require resuscitation. ANS:
D DIF: Cognitive Level: Implementation REF: p. 151, Table 6-7 22. The husband of a woman in labor asks, "What does it mean when the baby is at minus 1 station?" After giving an explanation, the nurse determines that teaching was effective when the husband states the fetal head is: a. above the ischial spines. ANS: A DIF: Cognitive Level: Application REF: p. 127, Figure 6-10 23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is: a.
pain related to increasing frequency and intensity of contractions. ANS: D DIF: Cognitive Level: Application REF: p. 147 OBJ: 6 24. The nurse caring for a patient who is not certain if she is in true labor will attempt to stimulate cervical effacement and intensify contractions in the patient by: a. offering the patient warm fluids to drink. ANS: B DIF: Cognitive Level: Comprehension REF: p. 131 OBJ: 5 25. When late decelerations occur, the nurse should: a. reposition the patient to supine. ANS: C DIF:
Cognitive Level: Application REF: p. 137 OBJ: 7 26. The nurse takes into consideration that the primary concern in the initial care of the newborn is maintaining: a. fluid intake.
ANS: C DIF: Cognitive Level: Knowledge REF: p. 150 OBJ: 7 MULTIPLE RESPONSE 27. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which intervention(s)? Select all that apply. a. Provide for extreme modesty. ANS: A, D, E DIF: Cognitive Level: Analysis REF: p. 117, Table 6-1 28. What are the advantages of a free-standing birth center? Select all that apply. a. Home-like setting ANS: A, C DIF: Cognitive Level: Application REF: p. 116 29. What do late decelerations indicate? Select all that apply. a. A
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What is the most important nursing intervention during the fourth stage of labour?For immediate postpartum, the nurse checks the vital signs and monitors for excessive bleeding. The first four hours after birth is sometimes referred to as the fourth stage of labor because this is the most critical period for the mother.
Why is voiding encouraged during the fourth stage of labor?Encourage frequent urination to keep bladder empty (full bladder prevents uterus from contracting properly and can slow down labor), monitor vitals of mother and fetal heart rate.
For which reason would the nurse encourage a client to void during the first stage of labor?2. Encourage the client to void. Voiding may enhance labor progress and reduce the risk of trauma to the bladder. A full bladder or bowel can impede fetal descent, so encourage the client to void, if possible, at least every 2 to 4 hours during labor.
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Why should the nurse encourage the mother to avoid during the fourth stage of labor quizlet?
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