Chapter 14- Nursing Management During Labor and Birth

1.A woman in labor who received an opioid for pain relief develops respiratory
depression. The nurse would expect which agent to be administered?
A)Butorphanol
B)Fentanyl
C)Naloxone
D)Promethazine
2.A clients membranes spontaneously ruptured, as evidenced by a gush of clear
fluid with a contraction. Which of the following would the nurse do next?
A)Check the fetal heart rate.
B)Perform a vaginal exam.
C)Notify the physician immediately.
D)Change the linen saver pad.
3.A woman has just entered the second stage of labor. The nurse would focus care
on which of the following?
A)Encouraging the woman to push when she has a strong desire to do so
B)Alleviating perineal discomfort with the application of ice packs
C)Palpating the womans fundus for position and firmness
D)Completing the identification process of the newborn with the mother
4.The nurse notes persistent early decelerations on the fetal monitoring strip. Which
of the following would the nurse do next?
A)Continue to monitor the FHR because this pattern is benign.
B)Perform a vaginal exam to assess cervical dilation and effacement.
C)Stay with the client while reporting the finding to the physician.
D)Administer oxygen after turning the client on her left side.
5.A woman is admitted to the labor and birthing suite. Vaginal examination reveals
that the presenting part is approximately 2 cm above the ischial spines. The nurse
documents this finding as:
A)+2 station
B)0 station

C2 station

D)Crowning
6.The nurse is performing Leopolds maneuvers to determine fetal presentation,
position, and lie. Which action would the nurse do first?
A)Feel for the fetal buttocks or head while palpating the abdomen.
B)Feel for the fetal back and limbs as the hands move laterally on the abdomen.
C)Palpate for the presenting part in the area just above the symphysis pubis.
D)Determine flexion by pressing downward toward the symphysis pubis.
7.A client states, I think my waters broke! I felt this gush of fluid between my legs.
The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if the
paper turns:
A)Yellow
B)Olive green
C)Pink
D)Blue
8.A woman in labor is to receive continuous internal electronic fetal monitoring. The
nurse reviews the womans medical record to ensure which of the following as being
required?
A)Intact membranes
B)Cervical dilation of 2 cm or more
C)Floating presenting fetal part
D)A neonatologist to insert the electrode
9.When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm,
accompanied by a decrease in variability and late decelerations. Which of the
following would the nurse do next?
A)Have the woman change her position.
B)Administer oxygen.
C)Notify the health care provider.
D)Continue to monitor the pattern every 15 minutes.
10.A woman in labor has chosen to use hydrotherapy as a method of pain relief.
Which statement by the woman would lead the nurse to suspect that the woman
needs additional teaching?
A)The warmth and buoyancy of the water has a nice relaxing effect.
B)I can stay in the bath for as long as I feel comfortable.

C)My cervix should be dilated more than 5 cm before I try using this method.
D)The temperature of the water should be at least 105 F.
11.A woman in labor received an opioid close to the time of birth. The nurse would
assess the newborn for which of the following?
A)Respiratory depression
B)Urinary retention
D)Hyperreflexia
12.When applying the ultrasound transducers for continuous external electronic
fetal monitoring, at which location would the nurse place the transducer to record
the FHR?
A)Over the uterine fundus where contractions are most intense
B)Above the umbilicus toward the right side of the diaphragm
C)Between the umbilicus and the symphysis pubis
D)Between the xiphoid process and umbilicus
13.After describing continuous internal electronic fetal monitoring to a laboring
woman and her partner, which of the following would indicate the need for
additional teaching?
A)This type of monitoring is the most accurate method for our baby.
B)Unfortunately, Im going to have to stay quite still in bed while it is in place.
C)This type of monitoring can only be used after my membranes rupture.
D Youll be inserting a special electrode into my babys scalp.
14.When planning the care of a woman in the active phase of labor, the nurse would
anticipate assessing the fetal heart rate at which interval?
A)Every 2 to 4 hours
B)Every 45 to 60 minutes
C)Every 15 to 30 minutes
D)Every 10 to 15 minutes
15.Which of the following is a priority when caring for a woman during the fourth
stage of labor?
A)Assessing the uterine fundus
B)Offering fluids as indicated
C)Encouraging the woman to void

D)Assisting with perineal care

16.When palpating the fundus during a contraction, the nurse notes that it feels like
a chin. The nurse interprets this finding as indicating which type of contraction?
A)Intense
B)Strong
C)Moderate
D)Mild
17.A nurse palpates a womans fundus to determine contraction intensity. Which of
the following would be most appropriate for the nurse to use for palpation?
A)Finger pads
B)Palm of the hand
C)Finger tips
D)Back of the hand
18.A womans amniotic fluid is noted to be cloudy. The nurse interprets this finding
as which of the following?
A)Normal
B)Possible infection
C)Meconium passage
D)Transient fetal hypoxia
19.After teaching a group of students about fetal heart rate patterns, the instructor
determines the need for additional teaching when the students identify which of the
following as indicating normal fetal acidbase status? (Select all that apply.)
A)Sinusoidal pattern
B)Recurrent variable decelerations
C)Fetal bradycardia
D)Absence of late decelerations
E Moderate baseline variability
20A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in
FHR below the baseline, appearing as a U-shape. The nurse interprets these
changes as reflecting which of the following?

A)Early decelerations
B)Variable decelerations
C)Prolonged decelerations
D)Late decelerations
21.A nurse is explaining the use of therapeutic touch as a pain relief measure during
labor. Which of the following would the nurse include in the explanation?
A This technique focuses on manipulating body tissues.
BThe technique requires focusing on a specific stimulus.
C)This technique redirects energy fields that lead to pain.
D)The technique involves light stroking of the abdomen with breathing.
22.A group of nursing students are reviewing the various medications used for pain
relief during labor. The students demonstrate understanding of the information
when they identify which agent as the most commonly used opioid?
A)Butorphanol
B)Nalbuphine
C)Fentanyl
D)Meperidine
23.A nurse is describing the different types of regional analgesia and anesthesia for
labor to a group of pregnant women. Which statement by the group indicates that
the teaching was successful?
A)We can get up and walk around after receiving combined spinalepidural
analgesia.
B)Higher anesthetic doses are needed for patient-controlled epidural analgesia.
C)A pudendal nerve block is highly effective for pain relief in the first stage of
labor.
D)Local infiltration using lidocaine is an appropriate method for controlling
contraction pain.
24.A nurse is completing the assessment of a woman admitted to the labor and
birth suite. Which of the following would the nurse expect to include as part of the
physical assessment? (Select all that apply.)
A)Current pregnancy history
B)Fundal height measurement
C)Support system

D)Estimated date of birth

E)Membrane status
F)Contraction pattern
25.A pregnant woman admitted to the labor and birth suite undergoes rapid HIV
testing and is found to be HIV-positive. Which of the following would the nurse
expect to include when developing a plan of care for this women? (Select all that
apply.)
A)Administration of penicillin G at the onset of labor
B)Avoidance of scalp electrodes for fetal monitoring
C)Refraining from obtaining fetal scalp blood for pH testing
D)Adminstering zidovudine at the onset of labor.
E)Electing for the use of forceps-assisted delivery
26.Which position would be most appropriate for the nurse to suggest as a comfort
measure to a woman who is in the first stage of labor? (Select all that apply.)
A)Walking with partner support
B)Straddling with forward leaning over a chair
C)Closed kneechest position
D)Rocking back and forth with foot on chair
E)Supine with legs raised at a 90-degree angle
27.Which of the following would be most appropriate for the nurse to suggest about
pushing to a woman in the second stage of labor?
A)Lying flat with your head elevated on two pillows makes pushing easier.
B)Choose whatever method you feel most comfortable with for pushing.
C) Let me help you decide when it is time to start pushing.
D)Bear down like youre having a bowel movement with every contraction.
28.A nurse is assessing a woman after birth and notes a second-degree laceration.
The nurse interprets this as indicating that the tear extends through which of the
following?
A)Skin
B)Muscles of perineal body
C)Anal sphincter

D)Anterior rectal wall

29.A nurse is assisting with the delivery of a newborn. The fetal head has just
emerged. Which of the following would be done next?
A)Suctioning of the mouth and nose
B)Clamping of the umbilical cord
C)Checking for the cord around the neck
D)Drying of the newborn
30.A nurse is providing care to a woman during the third stage of labor. Which of the
following would alert the nurse that the placenta is separating? (Select all that
apply.)
A)Boggy, soft uterus
B)Uterus becoming discoid shaped
C)Sudden gush of dark blood from the vagina
D)Shortening of the umbilical cord
Answer Key
1.C
2.A
3.A
4.A
5.C
6.A
7.D
8.B
9.C
10.D
11.A
12.C
13.B
14.C
15.A

16.C
17.A
18.B
19.A, B, C
20.B
21.C
22.D
23.A
24.B, E, F
25.B, C, D
26.A, B, D
27.B
28.B
29.C
30.C