Chapter 17
1) The nurse is caring for laboring patients. Which women are experiencing problems related
to a critical factor of labor?
1. Primip at 7 cm, fetus in military attitude
2. Multip at 3 cm, fetus in longitudinal lie
3. Primip at 4 cm, fetus with macrocephaly due to hydrocephalus
4. Multip at 6 cm, fetus at −2 station, mild contractions
5. Primip at 5 cm, fetal presenting part is right shoulder
Answer: 1,3,4,5
Rationale 1:
Attitude refers to the relationship of the fetal parts to one another. Military attitude is an
unflexed neck; normal fetal attitude is flexion of the neck. Military attitude creates a larger
diameter of the head fitting through the pelvis. This patient is experiencing a problem
between the maternal pelvis and the presenting part.
Rationale 2:
Lie refers to the relationship between the cephalocaudal axis of the mother to the
cephalocaudal axis of the fetal body; longitudinal lie is normal.
Rationale 3:
Hydrocephalus can lead to macrocephaly, or an abnormally large head. Macrocephalic babies
might not fit through the bony pelvis and could require birth by cesarean. This patient is
experiencing a problem between the maternal pelvis and the presenting part.
Rationale 4:
Station refers to how low in the pelvis the baby’s presenting part is; −2 station is high in the
pelvis. Contractions should be strong to cause fetal descent and cervical dilation. Mild
contractions will not move the baby down or open the cervix. This patient is experiencing a
problem between the maternal pelvis and the presenting part.
Rationale 5: The presenting part is the fetal part coming through the cervix. The occiput or
back of the baby’s head is the most common and most effective presenting part. A shoulder
presentation cannot deliver vaginally and will require a cesarean birth. This patient is
experiencing a problem between the maternal pelvis and the presenting part.
2) The charge nurse has received a shift change report. Which patient requires immediate
intervention?
1. Multip at 6 cm undergoing induction of labor, strong contractions every three minutes
2. Primip at 4 cm whose fetus is in a longitudinal lie with an cephalic presentation
3. Multip at 10 cm and fetus at +2 station experiencing a strong expulsion urge
4. Primip at 3 cm screaming in fear because her mother died during childbirth
Answer: 4
Rationale 1:
Strong contractions every three minutes are an adequate labor pattern during induction of
labor. This patient is experiencing no complications.
Rationale 2:
Longitudinal lie with cephalic presentation is a head-down position. This is expected.
Rationale 3:
10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to
push, which will facilitate the birth of the child. These are expected.
Rationale 4:
This patient is most likely fearful that she will die during labor if her mother died during
childbirth. It is very rare to die during childbirth in developing countries. The extreme fear
this patient is experiencing could stimulate the fight-or-flight mechanism and hormone
cascade, which can significantly slow the progress of her labor; screaming and muscle
tension increase the body’s oxygen consumption, and in extreme cases can lead to fetal
hypoxia. This patient requires education and a great deal of support and is therefore the top
priority.
3) The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2
cm in three hours of contractions occurring every five minutes. The best response by the
nurse is:
1. “Your cervix has also effaced, or thinned out, and that change in the cervix is also labor
progress.”
2. “When your perineal body thins out, your cervix will begin to dilate much faster than it is
now.”
3. “What did you expect? You’ve only had contractions for a few hours. Labor takes time.”
4. “The hormones that cause labor to begin are just getting to be at levels that will change
your cervix.”
Answer: 1
Rationale 1:
Cervical effacement must be nearly complete before cervical dilation takes place in primips.
This is why the labor and birth of a first baby usually take much less time than for subsequent
labor and births.
Rationale 2:
The perineal body thinning primarily occurs during the second stage of labor; it is not
expected now.
Rationale 3:
This reply is not therapeutic. Although it is true that this patient has only been in early labor
for a short time, and it is true that labor for a primip averages 12–24 hours, the nurse must
always be therapeutic in all communication.
Rationale 4:
The hormones that cause labor contractions do not directly cause cervical change; the
contractions cause the cervix to change.
4) The primiparous patient at 40 weeks’ gestation reports to the nurse that she has had
increased pelvic pressure and increased urinary frequency. Which response by the nurse is
best?
1. “Unless you have pain with urination, we don’t need to worry about it.”
2. “These symptoms usually mean the baby’s head has descended further.”
3. “Come in for an appointment today and we’ll check everything out.”
4. “This might indicate that the baby is no longer in a head down position.”
Answer: 2
Rationale 1:
Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not
signs of a urinary tract infection.
Rationale 2:
This is the best response because it most directly addresses what the patient has reported.
Increased pelvic pressure and urinary frequency are premonitory signs of labor.
Rationale 3:
There is no need for an additional appointment, as increased pelvic pressure and urinary
frequency are premonitory signs of labor.
Rationale 4:
The patient is experiencing premonitory signs of labor; the fetus changing to a breech
presentation would be experienced as fetal movement that was formerly felt in the upper
abdomen but now is down in the pelvis.
5) The primiparous patient at 39 weeks’ gestation calls the clinic and reports increased
bladder pressure but easier breathing and irregular, mild contractions. She also states that she
just cleaned the entire house. Which statement should the nurse make?
1. “You shouldn’t work so much at this point in pregnancy.”
2. “What you are describing is not commonly experienced in the last weeks.”
3. “Your body may be telling you it is going into labor soon.”
4. “If the bladder pressure continues, come in to the clinic tomorrow.”
Answer: 3
Rationale 1:
There is no indication that the patient should decrease her work schedule.
Rationale 2:
Lightening is a common and expected finding.
Rationale 3:
One of the premonitory signs of labor includes lightening: The baby drops lower into the
pelvis, which creates increased pelvic and bladder pressure but less pressure on the
diaphragm, which makes breathing easier.
Rationale 4:
Lightening does not indicate pathology, and therefore there is no need to come to the clinic if
the symptoms continue.
6) A 25-year-old woman is 38 weeks’ gestation with her first pregnancy. For the third time in
one week, she presents to the hospital with complaints that are determined to be suggestive of
false labor. Prior to discharge, the patient states, “I’m so embarrassed for thinking I was in
labor. I feel like a fool.” What is the nurse’s best response?
1. “We’ll discuss the differences between true labor and false labor so this doesn’t happen
again.”
2. “It’s impossible to distinguish between false labor and true labor.”
3. “Don’t feel bad. Everyone makes mistakes sometimes.”
4. “It’s very difficult to tell the difference between true and false labor. Please know we’re
here to take care of you whenever you need us.”
Answer: 4
Rationale 1:
Rather than reinforcing the woman’s incorrect interpretation of what she believed to be true
labor, the nurse should provide reassurance and ease the woman’s embarrassment.
Rationale 2:
While it may be difficult to subjectively distinguish between false labor and true labor,
vaginal examination can be performed to determine if cervical dilatation is occurring.
Rationale 3:
Instead of reinforcing the woman’s perception of having made an error, the nurse should
reassure her that her embarrassment is unwarranted.
Rationale 4:
Rather than reinforcing the woman’s incorrect interpretation of what she believed to be true
labor, the nurse should provide reassurance and ease the woman’s embarrassment.
7) The nurse is teaching a prenatal class about false labor. The nurse should teach patients
that false labor most likely will include which of the following?
1. Contractions that do not intensify while walking
2. An increase in the intensity and frequency of contractions
3. Progressive cervical effacement and dilatation
4. Pain in the abdomen that does not radiate
5. Increased thin vaginal secretions
Answer: 1,4
Rationale 1:
True labor contractions intensify while walking.
Rationale 2:
True labor results in increased intensity and frequency of contractions.
Rationale 3:
True labor results in progressive dilation.
Rationale 4:
True labor results in pain beginning low in the abdomen and radiating upward or into the
back.
Rationale 5: True labor results in an increase in vaginal secretions.
8) The nurse is caring for a laboring patient. A cervical exam indicates 8 cm dilation. The
patient is restless, frequently changing position in an attempt to get comfortable. Which
nursing action is most important?
1. Leave the patient alone so she can rest.
2. Ask the family to take a coffee and snack break.
3. Encourage the patient to have an epidural for pain.
4. Reassure the patient that she will not be left alone.
Answer: 4
Rationale 1:
The patient is in the transitional phase of the first stage of labor and will not want to be alone.
Rationale 2:
The patient is in the transitional phase of the first stage of labor. The family members might
want to take a break, but the patient will not want to be alone.
Rationale 3:
The patient is in the transitional phase of the first stage of labor. There is no indication that
the patient wants pain relief.
Rationale 4:
Because the patient is in the transitional phase of the first stage of labor, she will not want to
be left alone; staying with the patient and reassuring her that she will not be alone are the
highest priorities at this time.
9) During the fourth stage of labor, your patient’s assessment includes a BP of 110/60, pulse
90, and the fundus is firm midline and halfway between the symphysis pubis and the
umbilicus. The priority action of the nurse should be to:
1. Turn the patient onto her left side.
2. Place the bed in Trendelenburg position.
3. Massage the fundus.
4. Continue to monitor.
Answer: 4
Rationale 1:
A left lateral position is not necessary with a BP of 110/60 and a pulse of 90.
Rationale 2:
Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.
Rationale 3:
The uterus should be midline and firm; massage is not necessary.
Rationale 4:
The patient’s assessment data are normal for the fourth stage of labor, so monitoring is the
only action necessary. During the fourth stage of labor, the mother experiences a slight drop
in blood pressure and a slightly increased pulse.
10) A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions
are two minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal
pressure. How should the nurse interpret this complaint?
1. The patient’s complaint is congruent with her current stage of labor.
2. The patient’s complaint may indicate the need for delivery via cesarean section.
3. Based upon the patient’s complaint, she is experiencing the active phase of labor.
4. The patient’s complaint is consistent with placental separation, which is normal for her
current stage of labor.
Answer: 1
Rationale 1:
The objective findings and patient’s complaint are consistent with the transitional phase of
labor, during which the patient may experience increased rectal pressure as cervical dilatation
approaches 10 cm (3.9 in.).
Rationale 2:
The objective findings and patient’s complaint of increased rectal pressure are consistent with
the transitional phase of labor, during which the patient may experience increased rectal
pressure as cervical dilatation approaches 10 cm (3.9 in.).
Rationale 3:
The objective findings and patient’s complaint are consistent with the transitional phase of
labor, during which the patient may experience increased rectal pressure as cervical dilatation
approaches 10 cm (3.9 in.).
Rationale 4:
Placental separation occurs after the infant is born.
11) The labor and delivery nurse is reviewing charts. Of which patient should the nurse
inform the supervisor?
1. Multip at 5 cm requesting labor epidural analgesia
2. Primip whose cervix remains at 6 cm for four hours
3. Multip who has developed nausea and vomiting
4. Primip requesting her partner to stay with her
Answer: 2
Rationale 1:
Contacting the supervisor is required when an abnormal situation is present. A multip
requesting an epidural at 5 cm is not abnormal.
Rationale 2:
Average cervical change among primips in the active phase of the first stage of labor is 1.2
cm/hour; thus, this patient’s lack of cervical change is unexpected and should be reported to
the supervisor.
Rationale 3:
Nausea and vomiting are common during the transitional phase of the first stage of labor.
Contacting the supervisor is required only when an abnormal situation is present.
Rationale 4:
Patients in the transitional phase of the first stage of labor often fear being left alone; this is
an expected finding. Contacting the supervisor is required only when an abnormal situation is
present.
12) Which patient requires immediate intervention by the labor and delivery nurse?
1. Multip at 8 cm, systolic blood pressure has increased 35 mm Hg
2. Primip that delivered one hour ago with WBC of 50,000
3. Multip at 5 cm with a respiratory rate of 22 between contractions
4. Primip in active labor with urine output of 100 ml/hour
Answer: 2
Rationale 1:
The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and
can increase further in the second stage of labor.
Rationale 2:
A white count of 25,000–30,000 is normal at the end of labor and during the early postpartum
period. This white count is abnormally high and requires further assessment and provider
notification.
Rationale 3:
The respiratory rate increases during labor because uterine contractions increase oxygen
requirements. This patient requires no further intervention.
Rationale 4:
This is a normal urine output and requires no further intervention.
13) The labor and delivery nurse is preparing a prenatal class about facilitating the progress
of labor. Which of the following frequent responses to pain should the nurse indicate is most
likely to impede progress in labor?
1. Increased pulse
2. Elevated blood pressure
3. Muscle tension
4. Increased respirations
Answer: 3
Rationale 1:
Increased pulse is a manifestation of pain, but it does not impede labor.
Rationale 2:
Elevated blood pressure is a manifestation of pain, but it does not impede labor.
Rationale 3:
Muscle tension can impede labor progress by increased oxygen and calorie consumption and
by creating a mechanical obstruction that the uterine contractions must overcome to achieve
labor progress.
Rationale 4:
Increased respiration is a manifestation of pain, but it does not impede labor.
14) A healthy 18-year-old patient who is 40 weeks’ gestation presents at the clinic
complaining of vaginal expulsion of stringy mucus followed by blood-tinged secretions. She
denies any discomfort or any other changes. Based upon the patient’s complaints, what is
most likely to occur within the next 24 to 48 hours?
1. Onset of labor
2. Spontaneous abortion
3. Cesarean section
4. Chorioamnionitis
Answer: 1
Rationale 1:
Softening and effacement of the cervix is accompanied by expulsion of the mucous plug and
a small amount of blood loss from the exposed cervical capillaries. The resulting pink-tinged
secretions are called bloody show. Bloody show is considered a sign that labor will begin
within 24 to 48 hours.
Rationale 2:
The patient is most likely demonstrating expulsion of the mucous plug and bloody show,
which is considered a sign that labor will begin within 24 to 48 hours.
Rationale 3:
The patient is describing pregnancy-related changes associated with imminent onset of labor.
Based upon her report, there is no indication that cesarean section will be necessary.
Rationale 4:
Chorioamnionitis is associated with premature rupture of amniotic membranes (PROM).
Based upon the patient’s report, she is demonstrating mucus plug expulsion and bloody show.
15) While caring for a labor patient, the nurse determines during a vaginal exam that the
baby’s head has internally rotated. This information is given to the family. The labor support
person asks the nurse, “What other position changes will the baby undertake during labor and
birth?” How should the nurse describe the rest of the cardinal movements for a baby in a
vertex presentation?
1. Flexion, extension, restitution, external rotation, and expulsion
2. Expulsion, external rotation, and restitution
3. Restitution, flexion, external rotation, and expulsion
4. Extension, restitution, external rotation, and expulsion
Answer: 4
Rationale 1:
The fetus changes position in the following order: descent, engagement, flexion, internal
rotation, extension, restitution, external rotation, and expulsion.
Rationale 2:
The fetus changes position in the following order: descent, engagement, flexion, internal
rotation, extension, restitution, external rotation, and expulsion.
Rationale 3:
The fetus changes position in the following order: descent, engagement, flexion, internal
rotation, extension, restitution, external rotation, and expulsion.
Rationale 4:
The fetus changes position in the following order: descent, engagement, flexion, internal
rotation, extension, restitution, external rotation, and expulsion.
16) A patient in active labor is demonstrating intense contractions and demonstrates cervical
dilatation of 3 cm without rupture of amniotic membranes. The attending physician requests
an amnihook. What procedure does the nurse anticipate that the physician will perform?
1. Cesarean section
2. Placental separation
3. Cervical dilatation
4. Artificial rupture of membranes (AROM)
Answer: 4
Rationale 1:
Based upon the scenario, there is no indication for cesarean section. Rather, this patient likely
requires artificial rupture of amniotic membranes (AROM), which is performed using an
amnihook.
Rationale 2:
Placental separation usually occurs naturally, about 5 minutes after the birth of the newborn.
Based upon the scenario, this patient requires artificial rupture of amniotic membranes
(AROM).
Rationale 3:
Based upon this scenario, the patient is demonstrating cervical dilatation consistent with the
first stage of labor without rupture of amniotic membranes (ROM). She likely requires
artificial rupture of membranes (AROM), which is performed using an amnihook.
Rationale 4:
Based upon this scenario, the patient likely requires artificial rupture of membranes (AROM),
which is performed using an amnihook.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
