Chapter 20
1) The laboring patient has rated her pain at 9 on a scale of 1–10, and she requests IV pain
medication. She has refused epidural anesthesia, but her certified nurse-midwife (CNM) has
ordered butorphanol tartrate (Stadol) for administration to the patient. Which action should
the nurse complete next?
1. Advise the woman as to the actions and contraindications associated with butorphanol
tartrate and obtain her consent for administration of the medication.
2. Offer the woman epidural anesthesia once more and describe the effectiveness of this
method of labor pain control.
3. Obtain maternal vital signs and assess the fetal heart rate (FHR).
4. Administer oxygen via face mask at 6 to 10 liters per minute.
Answer: 1
Rationale 1:
Prior to administration of medication, the nurse must explain the pharmacologic effects of the
medication and obtain consent for administration.
Rationale 2:
The woman has refused epidural anesthesia but is authorized to receive butorphanol tartrate.
The nurse’s next step is to advise the woman as to the actions and contraindications
associated with butorphanol tartrate and obtain her consent for administration of the
medication.
Rationale 3:
Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the woman
as to the actions and contraindications associated with butorphanol tartrate and obtain her
consent for administration of the medication.
Rationale 4:
Routine oxygen administration is not indicated for administration of butorphanol tartrate to
an asymptomatic patient in labor. The nurse’s next step is to advise the woman as to the
actions and contraindications associated with butorphanol tartrate and obtain her consent for
administration of the medication.
2) A patient has just been admitted for labor and delivery. She is having mild contractions
every 15 minutes lasting 30 seconds. The patient wants to have a medication-free birth. When
discussing medication alternatives, the nurse should be sure the patient understands that:
1. In order to respect her wishes, no medication will be given.
2. Pain relief will allow a more enjoyable birth experience.
3. The use of medications allows the patient to rest and be less fatigued.
4. Maternal pain and stress can have a more adverse effect on the fetus than would a small
amount of analgesia.
Answer: 4
Rationale 1:
It is important to respect the patient’s wishes when possible. Once the effects are explained, it
is still the patient’s choice whether to receive medication.
Rationale 2:
While pain relief can lead to a more enjoyable experience, it might be the view of the nurse
but not the mother.
Rationale 3:
While pain relief can allow the mother to be less fatigued, it might be the view of the nurse
but not the mother.
Rationale 4:
The decision not to medicate should be an informed one, and it is possible that the patient
does not know about the effects pain and stress can have on the fetus. Once the effects are
explained, it is still the patient’s choice whether to receive medication.
3) The nurse has presented a teaching session on pain relief options to a prenatal class. Which
patient statement indicates that additional teaching is needed?
1. “An epidural can be continuous or one dose.”
2. “General anesthesia is usually recommended for a patient who delivers by way of cesarean
section.”
3. “Narcotics can be given through a patient’s epidural infusion catheter.”
4. “A pudendal block usually works well to control pain during episiotomy repair.”
Answer: 2
Rationale 1:
Epidural anesthesia can be administered in a single dose or via continuous infusion.
Rationale 2:
Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice
indicated in the management of patients undergoing cesarean section.
Rationale 3:
To provide analgesia for approximately 24 hours after the birth, the analgesia provider may
inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the
epidural space immediately after the birth
Rationale 4:
A pudendal block technique is given in the second stage of labor for the provision of perineal
anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy
repair.
4) The charge nurse is reviewing the plans of care for four laboring patients. Which care plan
requires immediate reconsideration for revision?
1. Administration of epidural anesthesia to a woman who is in the first stage of labor and has
a shellfish allergy
2. Administration of a spinal anesthetic to a woman who is scheduled for vaginal delivery of
her baby
3. Administration of epidural anesthesia to a woman with a history of vomiting secondary to
hyperemesis gravidarum
4. Administration of a spinal anesthetic to a woman with a history of irritable bowel
syndrome (IBS)
Answer: 3
Rationale 1:
A lumbar epidural relieves pain associated with the first and second stages of labor. An
allergy to shellfish is not a contraindication to epidural anesthesia.
Rationale 2:
Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for
vaginal birth.
Rationale 3:
Contraindications to epidural anesthesia include severe hypovolemia of any etiology. This
patient with hyperemesis gravidarum should be evaluated for severity of dehydration prior to
administration of epidural anesthesia.
Rationale 4:
Irritable bowel syndrome (IBS) does not represent a contraindication to spinal anesthesia.
5) Which of the following nursing actions can prevent or detect common side effects of
epidural anesthesia?
1. Preloading the patient with a rapid infusion of IV fluids
2. Continuing the patient on p.o. fluids only to prevent hypotension
3. Monitoring the FHR for late deceleration and decrease in rate
4. Use of intermittent FHR monitoring so the patient can use the birthing ball
Answer: 1,3
Rationale 1:
Hypotension can be prevented by preloading with rapid IV infusion followed by continuous
IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension
occurs. Continuing FHR monitoring is essential.
Rationale 2:
Hypotension can be prevented by preloading with rapid IV infusion followed by continuous
IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension
occurs. Continuing FHR monitoring is essential.
Rationale 3:
Hypotension can be prevented by preloading with rapid IV infusion followed by continuous
IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension
occurs. Continuing FHR monitoring is essential.
Rationale 4:
Hypotension can be prevented by preloading with rapid IV infusion followed by continuous
IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension
occurs. Continuing FHR monitoring is essential.
6) Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the
laboring patient in which of the following positions?
1. On her right side in the center of the bed with her back curved
2. Lying prone with a pillow under her chest
3. On her left side with the bottom leg straight and the top leg slightly flexed
4. Sitting on the edge of the bed with her back slightly curved and her feet on a stool
Answer: 4
Rationale 1:
Especially in pregnant women, this position is not ideal for facilitating access to the epidural
space.
Rationale 2:
This position is not consistent with access to the epidural spaces.
Rationale 3:
This position is not consistent with access to the epidural spaces.
Rationale 4:
Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the
epidural spaces to be accessed more easily.
7) The laboring patient requests pain medication. Her contractions are lasting 20–30 seconds
and are occurring every 8–20 minutes. The nurse would explain that analgesics given at this
time would likely cause:
1. Fetal respiratory depression.
2. Decreased analgesic effectiveness at the end of labor.
3. Maternal hypotension.
4. Prolonged labor.
Answer: 4
Rationale 1:
Pain medication given before established labor does not cause fetal respiratory depression
unless the mother delivers within an hour of receiving the medication. This is not likely if
labor is not established.
Rationale 2:
Medication given early in the labor process does not become less effective at the end of labor.
Rationale 3:
Analgesics might lower the blood pressure, but this effect does not cause the contraction
pattern to be altered.
Rationale 4:
Pain medication given before labor becomes established is likely to prolong the labor process.
8) During her hospital admission, the laboring patient explicitly refused all pain medications
and a labor epidural. Once dilated to 5 cm, the patient complains of intolerable discomfort
and asks the nurse, “If I have an epidural, how will you make sure it doesn’t hurt my baby?”
The best response by the nurse is:
1. “We’ll monitor your baby continuously so we can recognize and treat any changes that
may be related to the epidural.”
2. “Epidural anesthesia is very safe and there are no potential side effects that can affect your
baby.”
3. “We’ll assess your blood pressure every 15 minutes to make sure the epidural is not having
any negative effects on your baby.”
4. Before your epidural is placed, we’ll administer IV fluid to you in order to prevent the
epidural from causing you problems.”
Answer: 1
Rationale 1:
Continuous electronic fetal monitoring to assess fetal status is indicated in the care of
pregnant women who receive epidural anesthesia and allows for a more direct assessment of
fetal status than does frequent monitoring of maternal BP and pulse, which are also indicated
in the care of this patient.
Rationale 2:
While proficient administration and monitoring of epidural anesthesia allows for a high
degree of safety with this technique, maternal hypotension associated with epidural
anesthesia may produce harmful fetal effects.
Rationale 3:
While frequent monitoring of maternal blood pressure and pulse are indicated in the care of a
patient who receives a labor epidural, continuous electronic fetal monitoring is also indicated
for assessment of fetal status and allows for a more direct fetal assessment.
Rationale 4:
While administration of a bolus of IV fluid is indicated in preparation for epidural placement
and reduces the risk for maternal hypotension, this intervention neither guarantees the
prevention of related complications nor allows for assessment of fetal status.
9) The anesthesia provider has just administered an epidural anesthetic in a laboring patient
and local anesthesia is continuously infusing via the epidural catheter. Suddenly, the patient
asks, “Why are my ears ringing?” What is the most likely cause of the patient’s complaint?
1. Hypotension
2. Allergic reaction
3. Dehydration
4. Local anesthetic toxicity
Answer: 4
Rationale 1:
Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing
in the ears is associated with local anesthetic toxicity.
Rationale 2:
Sensation of ringing in the ears is associated with local anesthetic toxicity.
Rationale 3:
Sensation of ringing in the ears is associated with local anesthetic toxicity.
Rationale 4:
Sensation of ringing in the ears is associated with local anesthetic toxicity.
10) The nurse is caring for a laboring patient who is receiving continuous epidural anesthesia
via infusion. The maternal blood pressure decreases from 132/78 to 78/42. Which
intervention should the nurse implement first?
1. Increase the flow rate of infusion of intravenous crystalloid solution.
2. Verify the patient is positioned to promote left uterine displacement.
3. Administer oxygen.
4. Administer ephedrine 5 to 10 mg intravenously.
Answer: 1
Rationale 1:
If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate,
ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not
restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.
Rationale 2:
If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate,
ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not
restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.
Rationale 3:
If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate,
ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not
restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.
Rationale 4:
If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate,
ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not
restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered.
11) During admission, a laboring patient tells the nurse, “I’m so afraid I’ll need a cesarean
section. I don’t want to be asleep for surgery when my baby is born!” Which of the following
nursing responses is most appropriate?
1. “If a cesarean section is needed, that doesn’t necessarily mean you’ll need to go to sleep
for surgery.”
2. “Your anesthesia provider will require that you go to sleep for surgery.”
3. “We’ll do our best to make sure you deliver vaginally, so you don’t need to have a
cesarean section.”
4. “If you need a cesarean section, the anesthesia provider will awaken you as soon as
possible after delivery so that you can see your baby quickly.”
Answer: 1
Rationale 1:
While general anesthesia may be needed for cesarean birth and for surgical intervention with
some complications, in modern obstetrics, general anesthesia is used in less than 1% of all
obstetric births.
Rationale 2:
General anesthesia may be needed for cesarean birth and for surgical intervention with some
complications. However, in modern obstetrics, spinal anesthesia is often administered for
delivery via cesarean section, while general anesthesia is used in less than 1% of all obstetric
births.
Rationale 3:
Reassuring the patient in this manner does not address the erroneous belief that general
anesthesia is mandatory for women undergoing cesarean section.
Rationale 4:
Reassuring the patient in this manner does not address the erroneous belief that general
anesthesia is mandatory for women undergoing cesarean section.
12) A laboring patient has received an order for epidural anesthesia. In order to prevent the
most common complication associated with this procedure, the nurse would expect to do
which of the following?
1. Observe fetal heart rate variability.
2. Rapidly infuse 500–1,000 ml of intravenous fluids.
3. Place the patient in the semi-Fowler’s position.
4. Teach the patient appropriate breathing techniques.
Answer: 2
Rationale 1:
Administering a fluid bolus prior to an epidural generally prevents maternal hypotension,
which is the most common side effect of an epidural.
Rationale 2:
Administering a fluid bolus prior to an epidural generally prevents maternal hypotension,
which is the most common disadvantage to the procedure.
Rationale 3:
Administering a fluid bolus prior to an epidural generally prevents maternal hypotension,
which is the most common disadvantage to the procedure.
Rationale 4:
Administering a fluid bolus prior to an epidural generally prevents maternal hypotension,
which is the most common disadvantage to the procedure.
13) After receiving nalbuphine hydrochloride (Nubain), a woman’s labor progresses rapidly,
and the baby is born less than one hour later. The baby exhibits signs of respiratory
depression. Which medication should the nurse be prepared to administer to the newborn?
1. Fentanyl (Sublimaze)
2. Butorphanol tartrate (Stadol)
3. Naloxone (Narcan)
4. Pentobarbital (Nembutal)
Answer: 3
Rationale 1:
Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the
Nubain.
Rationale 2:
Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the
Nubain.
Rationale 3:
Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the
Nubain.
Rationale 4:
Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the
Nubain.
14) The patient at 39 weeks’ gestation is undergoing a Cesarean birth due to breech
presentation. General anesthesia is being used. Which potential challenge is most relevant to
the anesthesia care of this patient?
1. Hypotension due to the intense blockade of sympathetic fibers
2. Difficulty with maternal intubation
3. Broad ligament hematoma
4. Fetal depression that is fetal depression inversely proportional to maternal anesthetic depth
and duration
Answer: 2
Rationale 1:
Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of
sympathetic fibers that results in a high incidence of hypotension.
Rationale 2:
Difficulty with maternal intubation is a primary challenge of general anesthesia care for
pregnant patients.
Rationale 3:
Broad ligament hematoma is a complication associated with pudendal blockade.
Rationale 4:
Fetal depression associated with general anesthesia is directly proportional to maternal
anesthetic depth and duration.
15) Following spinal anesthesia for delivery of her baby, a woman reports an inability to void
urine. As the nurse palpates the woman’s bladder the woman says, “It’s been five hours since
I had my spinal and I still can’t empty my bladder. Do I have nerve damage?” How should
the nurse respond?
1. “Spinal anesthesia can sometimes cause nerve damage.”
2. “It may be several hours before you’re able to control your urination.”
3. “You should be able to control your bladder by now. I’ll ask the anesthesia provider to
visit with you.”
4. “You are probably dehydrated. Please increase your water intake.”
Answer: 2
Rationale 1:
Although nerve damage is a rare occurrence in relation to spinal anesthesia, there is no
objective data to suggest that this woman has experienced nerve damage. Restoration of
bladder control may take 8 to 12 hours following a spinal anesthetic.
Rationale 2:
Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.
Rationale 3:
Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.
Rationale 4:
There is no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a
common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12
hours following a spinal anesthetic.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
