Preview Extract
Chapter 19
1) The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement
indicates that teaching has been effective? “When a patient arrives in labor:
1. “A urine specimen is obtained by catheter to check for protein and ketones.”
2. “She will be positioned supine to facilitate a normal blood pressure.”
3. “Her prenatal record is reviewed for indications of domestic abuse.”
4. “A vaginal exam is performed if delivery appears to be imminent.”
Answer: 4
Rationale 1:
A midstream clean-catch specimen is obtained to assess for proteinuria and ketonuria.
Rationale 2:
Supine position predisposes the patient to supine hypotension syndrome; side-lying is
preferred.
Rationale 3:
Domestic abuse is not the sole reason the prenatal record is examined; any complications of
pregnancy are noted.
Rationale 4:
Unless delivery seems imminent because the patient is bearing down or contractions are very
close and strong, the vaginal exam is performed after the vital signs are obtained.
2) The patient presents to labor and delivery stating that her water broke two hours ago.
Indicators of normal labor include:
1. Fetal heart rate of 130 with average variability.
2. Blood pressure of 130/80.
3. Maternal pulse of 160.
4. Protein of +1 in urine.
5. Odorless, clear fluid on underwear.
Answer: 1,2,5
Rationale 1:
FHR 120–160 with variability is a normal indication.
Rationale 2:
Maternal vital sign of blood pressure below 140/70 is a normal indication.
Rationale 3:
A pulse of 60–100 is a normal indication.
Rationale 4:
Proteinuria of +1 or more could be a sign of pre-eclampsia.
Rationale 5:
Fluid clear and without odor is a normal indication.
3) The laboring patient and her partner have arrived at the birthing unit. Which step of the
admission process should be undertaken first?
1. The sterile vaginal exam
2. Welcoming the couple
3. Auscultation of the fetal heart rate
4. Checking for ruptured membranes
Answer: 2
Rationale 1:
The sterile vaginal exam should be performed after rapport has been established and maternal
vital signs have been assessed.
Rationale 2:
Establishing rapport will decrease anxiety of the couple and facilitate a more pleasant birth
experience.
Rationale 3:
Welcoming the couple is more important upon arrival.
Rationale 4:
Although assessing for intact or ruptured membranes is a part of the admission assessment,
welcoming the couple is more important upon arrival.
4) An expectant father has been at the bedside of his laboring partner for more than 12 hours.
An appropriate nursing intervention would be to:
1. Insist that he leave the room for at least the next hour.
2. Tell him he is not being as effective as he was and that he needs to let someone else take
over.
3. Offer to remain with his partner while he takes a break.
4. Suggest that the patient’s mother might be of more help.
Answer: 3
Rationale 1:
Insisting that the father leave does not reassure him about the care the woman will receive in
his absence.
Rationale 2:
Telling him that he is ineffective does not reassure him about the care the woman will receive
in his absence.
Rationale 3:
Support persons frequently are reluctant to leave the laboring woman to take care of their
own needs. Offering to stay with the woman so that he can take a break reassures the support
person that the woman will be well cared for in his absence.
Rationale 4:
Suggesting that the patient’s mother take his place does not reassure him about the care the
woman will receive in his absence.
5) The laboring patient has been found to be having moderately strong contractions lasting 60
seconds every 3 minutes. The fetal head is presenting at a −2 station. The cervix is 6 cm and
100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is
leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has
the highest priority?
1. Encourage the husband to remain in the room.
2. Keep the patient on bed rest at this time.
3. Apply an internal fetal scalp electrode.
4. Obtain a clean-catch urine specimen.
Answer: 2
Rationale 1:
It is unknown from the given information whether it is culturally appropriate for the patient’s
husband to remain in the room for the labor and birth.
Rationale 2:
Because the membranes are ruptured and the head is high in the pelvis at a −2 station, the
patient should be maintained on bed rest to prevent cord prolapse.
Rationale 3:
An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor.
This patient has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance
of labor are present.
Rationale 4:
A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid
contamination might falsely increase the protein present. Preventing cord prolapse, which is
life-threatening to the fetus, is a higher priority.
6) A healthy woman who is scheduled for elective cesarean birth is being admitted to the
hospital. Her surgery is scheduled to begin in 4 hours. The woman asks for a sip of coffee
with creamer. How should the nurse respond?
1. “Since you’re having surgery today, you’re not allowed to have anything to eat or drink.”
2. “You can drink black coffee.”
3. “You may have coffee with creamer.”
4. “You’re only allowed to drink water right now.”
Answer: 2
Rationale 1:
Avoiding both liquids and solids during labor, which was once standard practice, is no longer
so because evidence-based practice research and new guidelines indicate that clear fluids can
be consumed throughout labor and up to 2 hours before an elective cesarean birth.
Rationale 2:
Evidence-based practice research and new guidelines indicate that clear fluids can be
consumed throughout labor and up to 2 hours before an elective cesarean birth. Research
shows that the volume of liquid consumed is less important than the presence of particulate
matter ingested because this increases the risk of aspiration.
Rationale 3:
Evidence-based practice research and new guidelines indicate that clear fluids can be
consumed throughout labor and up to 2 hours before an elective cesarean birth. Research
shows that the volume of liquid consumed is less important than the presence of particulate
matter ingested because this increases the risk of aspiration. While black coffee is considered
a clear liquid, adding creamer would be contraindicated.
Rationale 4:
Evidence-based practice research and new guidelines indicate that clear fluids can be
consumed throughout labor and up to 2 hours before an elective cesarean birth. Research
shows that the volume of liquid consumed is less important than the presence of particulate
matter ingested because this increases the risk of aspiration. Black coffee is considered to be
a clear liquid.
7) Breathing techniques used in labor provide which of the following?
1. A form of anesthesia
2. A source of relaxation
3. An increased ability to cope with contractions
4. A source of distraction
Answer: 2,3,4
Rationale 1:
Breathing techniques do not provide a form of anesthesia.
Rationale 2:
When used correctly, breathing techniques can increase the woman’s pain threshold and
permit relaxation.
Rationale 3:
When used correctly, breathing techniques can enhance the ability to cope with contractions.
Rationale 4:
When used correctly, breathing techniques can provide a sense of control and allow the
uterus to function more effectively.
8) Five minutes after delivery, the neonate’s body is pink with blue extremities. The heart
rate is 150. The infant demonstrates a vigorous cry and good respiratory effort, and is actively
moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen.
When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing
interventions are appropriate?
1. Stimulation and resuscitative efforts
2. Oxygen via face mask and endotracheal suctioning
3. Rescue breathing and stimulation
4. Nasopharyngeal suctioning and blow-by oxygen
Answer: 4
Rationale 1:
The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition
who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called
“blow-by” oxygen).
Rationale 2:
The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition
who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called
“blow-by” oxygen).
Rationale 3:
The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition
who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called
“blow-by” oxygen).
Rationale 4:
The neonate’s APGAR score is 9; a score of 7 to 10 indicates a newborn in good condition
who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called
“blow-by” oxygen).
9) The neonatal nurse specialist is presenting a class to nursing students. When describing a
proper method for preventing heat loss in the neonate, which statement should the neonatal
nurse specialist include in his presentation?
1. “If the newborn is under a radiant-heated unit, he or she is dried, placed on a dry blanket,
and left uncovered under the radiant heat.”
2. “After delivery, the newborn is immediately placed in skin-to-skin contact with the
mother.”
3. “If a radiant-heated unit is used to keep the neonate warm, he or she is dried, wrapped in a
dry blanket, and placed under the radiant heat.”
4. “Immediately after delivery, the newborn is wrapped in a blanket and placed on the
mother’s chest.”
Answer: 1
Rationale 1:
If the newborn is under a radiant-heated unit, he or she is dried, placed on a dry blanket, and
left uncovered under the radiant heat. Because radiant heat warms the outer surface of
objects, a newborn wrapped in blankets will receive no benefit from radiant heat.
Rationale 2:
After delivery, the newborn is dried immediately and wet blankets are removed. Warmed
blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The
newborn may also be placed under a radiant-heated unit.
Rationale 3:
If the newborn is under a radiant-heated unit, he or she is dried, placed on a dry blanket, and
left uncovered under the radiant heat. Because radiant heat warms the outer surface of
objects, a newborn wrapped in blankets will receive no benefit from radiant heat.
Rationale 4:
After delivery, the newborn is dried immediately and wet blankets are removed. Warmed
blankets are applied or the newborn is placed in skin-to-skin contact with the mother. The
newborn may also be placed under a radiant-heated unit.
10) One minute after delivery, the neonate’s heart rate is 120 beats per minute. She
demonstrates a vigorous cry and is actively moving. The infant resists the nurse’s attempts to
straighten her arm. When the nurse flicks the soles of her feet, the infant grimaces. Her body
is pink and her extremities are blue. What APGAR score should the nurse assign to this
infant?
1. 9
2. 8
3. 7
4. 6
Answer: 2
Rationale 1:
Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry
correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing
in response to flicking of the soles correlates with 1 point and a pink body with blue
extremities correlates with 1 point. This infant’s APGAR score is 8.
Rationale 2:
Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry
correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing
in response to flicking of the soles correlates with 1 point and a pink body with blue
extremities correlates with 1 point. This infant’s APGAR score is 8.
Rationale 3:
Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry
correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing
in response to flicking of the soles correlates with 1 point and a pink body with blue
extremities correlates with 1 point. This infant’s APGAR score is 8.
Rationale 4:
Heart rate of greater than 100 beats per minute correlates with 2 points and vigorous cry
correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing
in response to flicking of the soles correlates with 1 point and a pink body with blue
extremities correlates with 1 point. This infant’s APGAR score is 8.
11) Upon delivery of the newborn, the nursing intervention that most promotes parental
attachment is:
1. Placing the newborn under the radiant warmer.
2. Placing the newborn on the maternal abdomen.
3. Allowing the mother a chance to rest immediately after delivery.
4. Taking the newborn to the nursery for the initial assessment.
Answer: 2
Rationale 1:
Removing the baby from the mother does not promote interaction.
Rationale 2:
Placing the baby on the maternal abdomen promotes attachment and bonding and gives the
mother a chance to interact with her baby immediately.
Rationale 3:
Removing the baby from the mother does not promote interaction.
Rationale 4:
Removing the baby from the mother does not promote interaction.
12) A young adolescent is transferred to the labor and delivery unit from the emergency
department. The patient is in active labor but did not know that she was pregnant. The most
important nursing action is to:
1. Determine who might be the father of the baby for paternity testing.
2. Ask the patient what kind of birthing experience she would like to have.
3. Assess blood pressure and check for proteinuria.
4. Obtain a Social Services referral to discuss adoption.
Answer: 3
Rationale 1:
Paternity testing is a lower priority than the physiologic well-being of the patient and fetus.
Rationale 2:
A patient with a previously undiagnosed pregnancy is unlikely to have given any thought to
childbearing preferences.
Rationale 3:
Pre-eclampsia is more common among adolescents than in young adults, and it is potentially
life-threatening to both the mother and fetus. This assessment is the highest priority.
Rationale 4:
During labor is an inappropriate time to discuss adoption or parenting. Wait until after the
birth to have this discussion when dealing with an adolescent who did not know she was
pregnant prior to the onset of labor.
13) As compared with admission considerations for an adult woman in labor, the nurse’s
priority for an adolescent in labor would be:
1. Cultural background.
2. Plans for keeping the infant.
3. Support persons.
4. Developmental level.
Answer: 4
Rationale 1:
Cultural background is important to planning anyone’s care.
Rationale 2:
Before considering this area, it is important to identify the adolescent’s level of development
so that a plan of care is consistent with the adolescent’s abilities.
Rationale 3:
Support person(s) are important to planning anyone’s care.
Rationale 4:
Knowing the adolescent’s level of development is also important when planning nursing care
for the mother who is keeping her infant.
14) The nurse encounters a woman giving birth at the local mall. What should the nurse do
first?
1. Apply counterpressure to the perineum.
2. Ask a bystander for a dry piece of clothing.
3. Visualize the perineum.
4. Determine if the membranes have ruptured.
Answer: 3
Rationale 1:
This is appropriate if the presenting part is crowning. Counterpressure to the perineum helps
prevent perineal lacerations.
Rationale 2:
Prior to birth, some dry cloth object should be obtained to dry the infant and prevent neonatal
hypothermia.
Rationale 3:
Inspecting the perineum is the only method of determining whether the patient is going to
give birth imminently. This is the top priority.
Rationale 4:
This is less important than knowing whether the baby is coming at this time.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
