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

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

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

 

Chapter 04: Physiologic and Psychological Changes During Pregnancy

 

Test Bank

 

MULTIPLE CHOICE

 

  1. A woman who is pregnant for the third time is referred to as a:
a. Nullipara
b. Primigravida
c. Multigravida
d. Grand multipara

 

 

ANS:  C

Gravida refers to the number of pregnancies, and the prefix multi indicates more than one. Therefore, anyone who has had more than one pregnancy is a multigravida.

 

DIF:    Cognitive Level: Knowledge          REF:   43                  OBJ:   1

TOP:   Terminology                                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A woman who is 8 weeks pregnant has a daughter age 5 and a son age 2. Previously, she had a spontaneous abortion at 12 weeks’ gestation. Therefore, she is gravida _____, para _____.
a. 3; 1
b. 3; 2
c. 4; 1
d. 4; 2

 

 

ANS:  D

She is in her fourth pregnancy, which means she is a gravida 4. Because she has delivered two children after 20 weeks’ gestation, she is a para 2.

 

DIF:    Cognitive Level: Comprehension   REF:   43-44             OBJ:   1

TOP:   Previous Obstetric History              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: N/A

 

  1. A woman’s last normal menstrual period began July 4. Using Nägele’s rule, what would be her estimated date of delivery?
a. April 1
b. April 11
c. May 11
d. May 29

 

 

ANS:  B

Using Nägele’s rule, add 7 days to the first day of the last menstrual period (LMP) to obtain the day (4 + 7 = 11). To determine the month, subtract 3 from the month of the LMP. (July is the seventh month, so 7 – 3 = 4 [April].) Therefore, the estimated due date is April 11.

 

DIF:    Cognitive Level: Knowledge          REF:   44                  OBJ:   2

TOP:   Determining Date of Birth              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: N/A

 

  1. A woman comes to the physician’s office because she has missed a menstrual period. She suspects she is pregnant because she has been nauseated in the morning and feels unusually tired. These are _____ signs of pregnancy.
a. Presumptive
b. Probable
c. Positive
d. Potential

 

 

ANS:  A

These signs and symptoms are common in the early stage of pregnancy. However, they only suggest pregnancy. They do not provide definitive evidence of pregnancy because they could be attributed to other causes.

 

DIF:    Cognitive Level: Comprehension   REF:   44-45 | Table 4-1

OBJ:   3                    TOP:   Signs of Pregnancy

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

  1. Which are classified as probable signs of pregnancy?
a. Linea nigra, abdominal enlargement, palpation of fetal outline
b. Abdominal enlargement, urinary frequency, quickening
c. Uterine enlargement, Hegar’s sign, positive pregnancy test
d. Quickening, Goodell’s sign, striae gravidarum

 

 

ANS:  C

Enlargement of the uterus, Hegar’s sign, and a positive pregnancy test are called probable signs of pregnancy because they indicate a woman is probably pregnant.

 

DIF:    Cognitive Level: Comprehension   REF:   44-45 | Table 4-1

OBJ:   3                    TOP:   Signs of Pregnancy

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

  1. A patient can be told that she is definitely pregnant when she has:
a. Positive pregnancy results
b. Uterine enlargement
c. Fetal heart sounds
d. Amenorrhea

 

 

ANS:  C

Pregnancy is definitely confirmed when positive signs are present. Positive signs of pregnancy include fetal heart sounds, fetal movements palpated by the examiner, and fetal outline visualized by ultrasound.

 

DIF:    Cognitive Level: Knowledge          REF:   44-45 | Table 4-1

OBJ:   3                    TOP:   Signs of Pregnancy

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

  1. A woman calls the clinic to report that she had a positive home pregnancy test and asks how reliable these are. The nurse’s most appropriate response is:
a. “The tests are 100% accurate.”
b. “Accuracy is very high if the test instructions are followed exactly.”
c. “The home kits test for hCG, which is not present until the third month of pregnancy.”
d. “Because they are highly inaccurate, these kits should not be relied on to diagnose pregnancy.”

 

 

ANS:  B

If done properly, these tests are about 97% accurate. Human chorionic gonadotropin (hCG) is present in the blood and urine around the end of the first week after conception.

 

DIF:    Cognitive Level: Application          REF:   44-45             OBJ:   3

TOP:   Signs of Pregnancy                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The laboratory test used to confirm pregnancy measures:
a. Estrogen
b. Progesterone
c. Human chorionic gonadotropin (hCG)
d. Follicle-stimulating hormone

 

 

ANS:  C

The hormone hCG is produced by the chorionic villi of the placenta. It is present in the pregnant woman’s blood and urine as early as 1 week after ovulation.

 

DIF:    Cognitive Level: Knowledge          REF:   45                  OBJ:   4

TOP:   Signs of Pregnancy                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: N/A

 

  1. The mother’s first recognition of fetal movements is referred to as:
a. Lightening
b. Quickening
c. Ballottement
d. Engagement

 

 

ANS:  B

The pregnant woman usually senses the fetal movements between 18 and 20 weeks’ gestation. The first time this occurs is referred to as quickening.

 

DIF:    Cognitive Level: Knowledge          REF:   44-45 | Table 4-1

OBJ:   N/A                TOP:   Signs of Pregnancy                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which change is related to increased progesterone levels?
a. Increased smooth muscle tone
b. Braxton-Hicks contractions
c. Deepening of the voice
d. Sodium retention

 

 

ANS:  C

Progesterone causes enlargement of the vocal cords, which deepens the voice. It also decreases smooth muscle tone to prevent abortion, and stimulates sodium secretion.

 

DIF:    Cognitive Level: Comprehension   REF:   52                  OBJ:   4

TOP:   Changes in Respiratory System (Epistaxis)                                KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which of the following is the cause of lordosis in pregnancy?
a. Tilting the thorax back relieves discomfort caused by muscle strain.
b. Softening of the pelvic joints decreases the support of the spinal column.
c. Loss of muscle tone makes the woman unable to maintain good posture.
d. As the uterus enlarges, the center of gravity shifts, causing the woman to lean back.

 

 

ANS:  D

As the uterus enlarges and becomes heavier, the mother’s center of gravity shifts forward. Progressive curvature of the spine enables her to maintain balance.

 

DIF:    Cognitive Level: Comprehension   REF:   53                  OBJ:   9

TOP:   Changes in Integumentary and Skeletal Systems             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which finding in a pregnant patient would require further assessment by the nurse?
a. Heart rate of 90
b. Blood volume increase by 35%
c. Blood pressure of 150/92
d. White blood cell count of 16,000/mm3

 

 

ANS:  C

An increased blood pressure in pregnancy requires further assessment. Increased heart rate, blood volume, and white blood cells are normal during physiologic changes during pregnancy.

 

DIF:    Cognitive Level: Analysis               REF:   50-51 | Table 4-4

OBJ:   5                    TOP:   Changes in Cardiovascular System KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A patient in her third trimester of pregnancy complains of dizziness and faintness when she lies on her back. Which statement by the nurse is most appropriate?
a. “Don’t worry, you don’t have long to go until delivery.”
b. “To improve the symptoms, lie on your left side instead of your back.”
c. “The symptoms are due to an increase in cardiac output when you lie down.”
d. “You will sleep more comfortably in a recliner.”

 

 

ANS:  B

Supine hypotensive syndrome is a drop in cardiac output that may occur in the third trimester as a result of pressure on the inferior vena cava by the enlarged uterus. Cardiac output is best when lying on the left side.

 

DIF:    Cognitive Level: Application          REF:   50-52 | Table 4-4 | Figure 4-3

OBJ:   6                    TOP:   Changes in Cardiovascular System KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A pregnant woman diagnosed with anemia says, “I don’t see how I could be anemic. I have been very careful to take iron tablets and to eat a balanced diet.” The nurse’s most appropriate response is:
a. “Have you had any bleeding that might have caused this?”
b. “It is normal to be anemic during pregnancy, so don’t worry about it.”
c. “During pregnancy, the fluid portion of your blood increases, which dilutes your red blood cells.”
d. “You need additional red blood cells to supply your baby’s oxygen needs. Too many of your blood cells are going to your baby.”

 

 

ANS:  C

Both plasma and red blood cells (RBCs) increase during pregnancy, but the increase in plasma exceeds the increase in RBCs. This essentially dilutes the RBCs so that the patient’s hemoglobin and hematocrit fall. The patient’s hemoglobin and hematocrit should be measured routinely. A hemoglobin below 11 g/dL or a hematocrit below 35% merits evaluation for anemia.

 

DIF:    Cognitive Level: Application          REF:   50-52 | Tables 4-4 and 4-5

OBJ:   5                    TOP:   Changes in Cardiovascular System

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Changes in the gastrointestinal system during pregnancy include:
a. Increased saliva production
b. Increased peristalsis
c. Decreased resistance of maternal tissue to insulin
d. Constriction of the cardiac sphincter of the stomach

 

 

ANS:  A

During pregnancy, increased estrogen causes ptyalism (increased saliva production); peristalsis decreases due to increased progesterone; insulin resistance develops; and the cardiac sphincter relaxes, which permits reflux of gastric contents and heartburn.

 

DIF:    Cognitive Level: Comprehension   REF:   52                  OBJ:   4

TOP:   Changes in Gastrointestinal System                                           KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. One cause of frequent urination during pregnancy is:
a. More rapid flow of urine to the bladder
b. Pressure of the gravid uterus on the bladder
c. Stasis of urine in the ureters
d. Decreased renal blood flow

 

 

ANS:  B

During early pregnancy, the growing uterus puts pressure on the bladder, causing frequent urination. In late pregnancy, the uterus with the growing fetus settles into the pelvic cavity, again putting pressure on the bladder. Urine flows to the bladder more slowly (not more rapidly). Stasis of urine in the ureters occurs but would not cause frequency. Renal blood flow increases, rather than decreases.

 

DIF:    Cognitive Level: Comprehension   REF:   52-53             OBJ:   7

TOP:   Changes in Renal System               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Melanocyte-stimulating hormone (MSH) is responsible for which of the following signs of pregnancy?
a. Nausea and vomiting
b. Feelings of warmth
c. Linea nigra
d. Breast enlargement

 

 

ANS:  C

MSH and estrogen cause increased skin pigmentation such as linea nigra and chloasma.

 

DIF:    Cognitive Level: Comprehension   REF:   53-54             OBJ:   8

TOP:   Changes in Integumentary and Skeletal Systems             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A woman in her second trimester of pregnancy smiles and pats her abdomen when she feels the baby move. She expresses a wish for a beautiful little girl and often talks about the baby in positive terms. These behaviors illustrate which developmental task of pregnancy?
a. Pregnancy validation
b. Fetal embodiment
c. Fetal distinction
d. Role transition

 

 

ANS:  C

When the mother achieves the task of fetal distinction, she begins to think of the fetus as distinct and separate from herself. Typically, she daydreams and talks about the baby, envisioning a perfect, beautiful baby.

 

DIF:    Cognitive Level: Comprehension   REF:   56                  OBJ:   12

TOP:   Developmental Tasks                                KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A woman who is 36 weeks pregnant tells the clinic nurse that she is considering taking ibuprofen for her back pain and muscle cramps. The nurse’s best response is:
a. “That is a good choice for pain relief.”
b. “Taking that mediation could cause your baby to experience distress because of premature changes in its cardiovascular system.”
c. “Instead of using ibuprofen, you should take aspirin for the pain.”
d. “Any of the over-the-counter pain relievers would be fine.”

 

 

ANS:  B

Use of ibuprofen during the third trimester can cause early closure of the ductus arteriosus. All women of childbearing age should be counseled about the risk of ingesting any drug during pregnancy and lactation.

 

DIF:    Cognitive Level: Application          REF:   54                  OBJ:   10

TOP:   Effect of Pregnancy and Lactation on Medication Ingestion

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which hormone stimulates uterine contractions and the milk ejection reflex in breastfeeding?
a. Progesterone
b. Estrogen
c. Oxytocin
d. Testosterone

 

 

ANS:  C

Oxytocin, a posterior pituitary hormone, contracts the uterus before and after delivery and causes milk ejection during breastfeeding.

 

DIF:    Cognitive Level: Knowledge          REF:   49-50 | Table 4-3

OBJ:   4                    TOP:   Changes in Endocrine System        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A patient tells the nurse that she is worried because her partner does not seem interested in the pregnancy. Which response by the nurse would be the most appropriate?
a. “Your partner probably did not want a child.”
b. “Your partner will go through stages of adjustment to fatherhood.”
c. “It would be a good idea for you to see a counselor as soon as possible.”
d. “If he doesn’t show more interest by the second trimester, he won’t be able to bond with the baby.”

 

 

ANS:  B

Although the major focus of pregnancy is the mother and baby, the partner also travels through stages of adjustment to fatherhood. Cultural values influence the role of the father, so the nurse should not assume that a father is not interested if he takes a less active role during the pregnancy and birth process.

 

DIF:    Cognitive Level: Application          REF:   56                  OBJ:   12-13

TOP:   Responses to Pregnancy: Impact on the Father                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. The nurse is interviewing a woman in the clinic who thinks she might be pregnant. Which are presumptive signs of pregnancy? (Select all that apply.)
a. Amenorrhea
b. Goodell’s sign
c. Uterine enlargement
d. Fatigue
e. Breast tenderness
f. Fetal heart sounds heard

 

 

ANS:  A, D, E

Amenorrhea, fatigue, and breast tenderness are presumptive signs of pregnancy. Goodell’s sign and uterine enlargement are probable signs, and auscultation of fetal heart sounds is a positive sign of pregnancy.

 

DIF:    Cognitive Level: Comprehension   REF:   44-45 | Table 4-1

OBJ:   3                    TOP:   Signs of Pregnancy

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

COMPLETION

 

  1. A pregnant woman has three living children, one single and one twin birth, one preterm birth, and no abortions. According to GTPALM, the nurse would record her pregnancy history as __________.

 

ANS:

4-2-1-0-3-1

GTPALM is a systematic, quick way to identify not only the number of pregnancies a woman has had, but also the outcomes of each one. It stands for G (gravida), T (number of term pregnancies), P (number of preterm deliveries), A (number of abortions), L (number of live births), and M (number of multiple births).

 

DIF:    Cognitive Level: Comprehension   REF:   43-44 | Box 4-1

OBJ:   1                    TOP:   Previous Obstetric History

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

Chapter 06: Process of Normal Labor

 

Test Bank

 

MULTIPLE CHOICE

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Application          REF:   99                  OBJ:   3

TOP:   Spontaneous Rupture of Membranes

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

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

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Application          REF:   98                  OBJ:   2

TOP:   Lightening      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Comprehension   REF:   96                  OBJ:   2

TOP:   Effect of Contractions on Cervix   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Comprehension   REF:   96                  OBJ:   2

TOP:   Effect of Contractions on Cervix   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Knowledge          REF:   99                  OBJ:   8

TOP:   False Labor    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Comprehension   REF:   92-93             OBJ:   10

TOP:   Fetal Presentation                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Comprehension   REF:   93-95 | Box 6-1

OBJ:   11                  TOP:   Fetal Position

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Knowledge          REF:   93-95             OBJ:   12

TOP:   Station            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Knowledge          REF:   94-95             OBJ:   12

TOP:   Station            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

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

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Comprehension   REF:   93-95 | Box 6-1

OBJ:   11                  TOP:   Fetal Position                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Comprehension   REF:   96                  OBJ:   6

TOP:   The Uterine Contraction                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Application          REF:   96 | 98            OBJ:   7

TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Comprehension   REF:   99-101 | Figure 6-7

OBJ:   14                  TOP:   Mechanisms of Labor                               KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Knowledge          REF:   101                OBJ:   14

TOP:   Four Stages of Labor                                 KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Analysis               REF:   101-102 | Box 6-2

OBJ:   14                  TOP:   Four Stages of Labor

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Knowledge          REF:   102                OBJ:   14

TOP:   Four Stages of Labor                                 KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Application          REF:   102                OBJ:   14

TOP:   Four Stages of Labor                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Comprehension   REF:   103-104 | Table 6-2

OBJ:   15                  TOP:   Physiologic Changes in Labor        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Comprehension   REF:   103-104 | Table 6-2

OBJ:   15                  TOP:   Physiologic Changes in Labor        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Analysis               REF:   103 | Table 6-2

OBJ:   15                  TOP:   Physiologic Changes in Labor

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Application          REF:   92-95             OBJ:   5

TOP:   Powers: Uterine Contractions | Cervical Changes |  Passenger: Station

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Application          REF:   92-95 | Figures 6-3 and 6-4 | Box 6-1

OBJ:   10-11             TOP:   Fetopelvic Relationship: Terminology

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Knowledge          REF:   97-98 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  C

The strength of a contraction is called its intensity.

 

DIF:    Cognitive Level: Knowledge          REF:   97-98 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  A

The increment is the period of increasing strength of a contraction.

 

DIF:    Cognitive Level: Knowledge          REF:   96-97 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Application          REF:   96-98 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Knowledge          REF:   96-97 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Application          REF:   97-98 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

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

 

 

ANS:  B

The decrement is the period of decreasing strength of a contraction.

 

DIF:    Cognitive Level: Knowledge          REF:   96-97 | Figure 6-6

OBJ:   9                    TOP:   Characteristics of Uterine (Labor) Contractions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

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

 

 

ANS:  A, C, D, E

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

 

DIF:    Cognitive Level: Comprehension   REF:   92                  OBJ:   5

TOP:   Major Variables in the Birth Process                                          KEY:   Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance

 

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

 

 

ANS:  A, C, F

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

 

DIF:    Cognitive Level: Analysis               REF:   99                  OBJ:   3

TOP:   Spontaneous Rupture of Membranes

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiologic Integrity

 

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

 

 

ANS:  A, B, E

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

 

DIF:    Cognitive Level: Application          REF:   98-99             OBJ:   4

TOP:   Events Before Onset of Labor        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

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