Chapter 23
1) The nurse is scheduling a patient for an external cephalic version (ECV). Which finding in
the patient’s chart requires immediate intervention?
1. “Multip, transverse lie.”
2. “Primip, frank breech ballotable.”
3. “Multip, 32 weeks, complete breech.”
4. “Primip, failed ECV last week.”
Answer: 3
Rationale 1:
This patient has no contraindication to ECV.
Rationale 2:
This patient has no contraindication to ECV.
Rationale 3:
ECV is not attempted until 36 weeks. This patient is too early in her pregnancy for ECV.
Rationale 4:
Although this patient is less likely to have a successful ECV this week if it was unsuccessful
last week, there is no contraindication to attempting the procedure.
2) The clinical nurse coordinator is meeting with a group of nursing students in post
conference to teach about caring for women who undergo artificial rupture of membranes
(AROM) by way of amniotomy. Which nursing student’s statement indicates that the
teaching has been effective?
1. “For women who undergo artificial rupture of membranes, vaginal examinations should be
limited.”
2. “In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial
rupture of membranes is performed.”
3. “Amniotomy is contraindicated for use in labor augmentation.”
4. “Women who undergo artificial rupture of membranes should be advised that they will
experience a ‘dry birth.’”
Answer: 1
Rationale 1:
Following artificial rupture of membranes (AROM), because there is now an open pathway
for organisms to ascend into the uterus, the number of vaginal exams must be kept to a
minimum to reduce the chance of introducing an infection.
Rationale 2:
In all cases, the fetal heart rate (FHR) is assessed just before and immediately after the
amniotomy, and the two FHR assessments are compared.
Rationale 3:
Amniotomy is an accepted method of labor augmentation.
Rationale 4:
Women need to know that amniotic fluid is constantly produced because some women may
worry that they will experience a “dry birth.”
3) Induction of labor is planned for a 31-year-old primip due to insulin-dependent diabetes.
The patient is 39 weeks’ gestation. She reports that she feels as though her baby has “flipped”
in her abdomen. Which nursing action is most important?
1. Evaluate fetal maturity.
2. Administer dinoprostone (Prepidil ) vaginal gel.
3. Implement continuous electronic fetal monitoring (EFM).
4. Notify the patient’s physician that the patient feels as though her baby has changed
position.
Answer: 4
Rationale 1:
Malpresentation, such as breech, is a relative contraindication to induction of labor. Before
proceeding with preparation for induction of labor, the patient will require additional
evaluation by her physician before proceeding.
Rationale 2:
Malpresentation, such as breech, is a relative contraindication to induction of labor. Before
proceeding with preparation for induction of labor, the patient will require additional
evaluation by her physician before proceeding.
Rationale 3:
Malpresentation, such as breech, is a relative contraindication to induction of labor. Before
proceeding with preparation for induction of labor, the patient will require additional
evaluation by her physician before proceeding.
Rationale 4:
Because malpresentation, such as breech, is a relative contraindication to induction of labor,
the patient will require additional evaluation by her physician before proceeding.
4) The nurse is teaching childbirth education classes. Teaching has been successful if the
primiparous patient states: “I can reduce the likelihood that I’ll tear or need an episiotomy if
I:
1. “Push in a semi-sitting position.”
2. “Make sure I push long and hard.”
3. “Begin regular perineal massage.”
4. “Pull back on my legs when pushing.”
Answer: 3
Rationale 1:
Semi-sitting or lithotomy position increases the likelihood of perineal lacerations.
Rationale 2:
Short pushes during the expulsion of the head decrease the likelihood of perineal lacerations.
Rationale 3:
Perineal massage has been shown to decrease the need for episiotomy in primiparous
patients.
Rationale 4:
Pulling back on the legs while pushing tightens the perineal tissue, which in turn increases the
likelihood of perineal lacerations.
5) The nurse is completing discharge teaching for a patient who delivered two days ago.
Which statement indicates that further information is required?
1. “Because I have a midline episiotomy, I should keep my perineum clean.”
2. “Soaking in the tub will help my mediolateral episiotomy to heal.”
3. “I can take ibuprofen (Motrin) when my perineum starts to hurt.”
4. “The tear I have through my rectum is unrelated to my episiotomy.”
Answer: 4
Rationale 1:
Perineal hygiene is important when a patient has an episiotomy to prevent infection and
facilitate healing.
Rationale 2:
Warm tub baths are helpful to facilitate both comfort and healing of an episiotomy.
Rationale 3:
Healing episiotomies can be very painful, and pain medication should be provided for
patients experiencing pain.
Rationale 4:
This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum.
6) The patient requires vacuum extraction assistance. To provide easier access to the fetal
head, the physician cuts a mediolateral episiotomy. After delivery, the patient asks what kind
of episiotomy was performed. What is the best response for the nurse to make? “The
episiotomy”:
1. “Goes straight back toward your rectum.”
2. “Is from your vagina toward the urethra.”
3. “Is cut diagonally away from your vagina.”
4. “Extends from your vagina into your rectum.”
Answer: 3
Rationale 1:
Midline episiotomy is straight back from the vagina toward the rectum.
Rationale 2:
Episiotomies are not cut anteriorly toward the urethra unless the patient has had a female
circumcision.
Rationale 3:
Mediolateral episiotomy is angled from the vaginal opening toward the buttock.
Rationale 4:
Extension into the rectum is a fourth-degree laceration.
7) The patient is recovering from a delivery that included a midline episiotomy. Her
perineum is swollen and sore. The patient is asking for her ice pack to be refreshed. The best
response from the nurse is:
1. “I’ll get you one right away.”
2. “You only need to use one ice pack.”
3. “You need to leave it off for at least 20 minutes and then reapply.”
4. “I’ll bring you an extra so that you can change it when you are ready.”
Answer: 3
Rationale 1:
Providing an additional ice pack before 20 minutes have passed would increase the perineal
edema.
Rationale 2:
More than one ice pack must be used in order to apply ice for 20 minutes on, followed by 20
minutes off.
Rationale 3:
Optimal effects from the use of an ice pack occur when it is applied for 20–30 minutes and
then removed for at least 20 minutes before being reapplied.
Rationale 4:
An ice pack that is provided now for use in 20 minutes would be melted before being used.
8) The nurse is training a nurse new to the labor and delivery unit. They are caring for a
laboring patient who is undergoing a forceps delivery. Which action requires intervention?
1. Regional anesthesia is administered via pudendal block.
2. The patient is instructed to push between contractions.
3. Fetal heart tones are consistently between 110 and 115.
4. Bladder is emptied using a straight catheter.
Answer: 2
Rationale 1:
Regional anesthesia is important to facilitate application of the forceps and cooperation with
pushing efforts.
Rationale 2:
The patient should only push during contractions, not between contractions.
Rationale 3:
These are normal fetal heart tones. No intervention is needed.
Rationale 4:
The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal
head.
9) The patient has been pushing for two hours and is exhausted. The physician is performing
a vacuum extraction birth. What finding is expected?
1. The head is delivered after eight pulls during contractions.
2. A bruise is present on the occiput that does not cross the suture line.
3. The location of the vacuum is apparent on the fetal scalp after birth.
4. Positive pressure is applied by the vacuum extraction during contractions.
Answer: 3
Rationale 1:
Use of the vacuum extraction for eight contractions is too many and can create damage to the
fetal head. If fetal descent does not occur with the first two pulls, the procedure should be
discontinued, and cesarean birth should take place.
Rationale 2:
This is a cephalohematoma and is a complication of vacuum extraction birth.
Rationale 3:
Caput in the shape of the vacuum cup is usually present immediately after birth and resolves
in 2–3 days.
Rationale 4:
Negative pressure is suction, which is needed to use the vacuum extractor to facilitate birth.
10) The patient has been pushing for two hours and is exhausted. The fetal head is visible
between contractions. The physician informs the patient that a vacuum extractor could be
used to facilitate the delivery. Which statement indicates that the patient needs additional
information about vacuum extraction assistance?
1. “A small cup will be put onto the baby’s head, and a gentle suction will be applied.”
2. “I can stop pushing and just rest if the vacuum extractor is used.”
3. “The baby’s head might have a bruise from the vacuum cup.”
4. “The vacuum will be applied for a total of ten minutes or less.”
Answer: 2
Rationale 1:
The vacuum extractor is a small cup-shaped device that is applied to the scalp.
Rationale 2:
Vacuum extraction is an assistive delivery, and the patient must continue with pushing efforts
to accomplish the birth.
Rationale 3:
The vacuum extractor might leave a bruise on the scalp where the device is placed.
Rationale 4:
The vacuum extractor is applied to the scalp for up to 10 minutes total.
11) The nurse is reviewing charts of patients who underwent cesarean births by request in the
last two years. The hospital is attempting to decrease costs of maternity care. What findings
contribute to increased healthcare costs in patients undergoing cesarean birth by request?
1. Increased abnormal placenta implantation in subsequent pregnancies
2. Decreased use of general anesthesia with greater use of epidural anesthesia
3. Prolonged anemia, requiring blood transfusions every few months
4. Coordination of career projects of both partners leading to increased income
Answer: 1
Rationale 1:
Placenta implantation problems are more common after cesarean birth and increase
healthcare costs because of the high risk care and testing required.
Rationale 2:
Which anesthesia method is used is not a significant factor in health care costs of cesarean
birth by request. The need for anesthesia, use of the operating suite, equipment use,
personnel, and other factors are more responsible for greater costs of cesarean birth compared
with vaginal birth.
Rationale 3:
This is not a complication of cesarean birth by request.
Rationale 4:
The income of the couple does not affect healthcare costs directly.
12) The patient had a classical uterine incision for her cesarean birth. The nurse knows that
the patient understands implications for future pregnancies that are secondary to her classical
uterine incision when the patient states:
1. “The next time I have a baby, I can try to deliver vaginally.”
2. “The risk of rupturing my uterus is too high for me to have any more babies.”
3. “Every time I have a baby, I will have to have a cesarean delivery.”
4. “I can only have one more baby.”
Answer: 3
Rationale 1:
Attempting a vaginal birth is contraindicated, and future births will be planned cesareans.
Rationale 2:
Future pregnancies are not prohibited.
Rationale 3:
A classical uterine incision is made in the upper uterine segment and holds an increased risk
of rupture in subsequent pregnancy, labor, and birth.
Rationale 4:
Future pregnancies are not limited to one.
13) After being in labor for several hours with no progress, the patient is diagnosed with
cephalopelvic disproportion (CPD) and must have a cesarean section. The patient is being
prepared for a cesarean delivery in the operating room. The doctor is present. The nurse
knows that the last assessment the nurse should make just prior to the patient’s being draped
for surgery is:
1. Maternal temperature.
2. Maternal urine output.
3. Vaginal exam.
4. Fetal heart tones.
Answer: 4
Rationale 1:
Maternal temperature is monitored by anesthesia personnel.
Rationale 2:
Maternal urine output is not significant at this point.
Rationale 3:
Vaginal exam is unnecessary when cephalopelvic disproportion (CPD) is present.
Rationale 4:
Fetal heart tones are assessed just prior to the start of surgery because the supine position can
lead to fetal hypoxia.
14) The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by
a participant indicates that additional information is needed?
1. “Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC.”
2. “My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is
head-down.”
3. “Because my hospital is so small and in a rural area, they won’t let me attempt a VBAC.”
4. “The rate of complications from VBAC is lower than the rate of complications from a
cesarean.”
Answer: 1
Rationale 1:
Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in
deciding if VBAC is advisable. Classical vertical incisions on the uterus have a higher rate of
rupture and should not be attempted.
Rationale 2:
Non-repeating conditions such as any non-vertex presentation might make VBAC a viable
option as long as this pregnancy is vertex.
Rationale 3:
A repeat cesarean must be able to be performed immediately to safely attempt a VBAC.
Many small and rural hospitals do not have surgical and anesthesia staff available at night,
and on weekends and holidays, and therefore do not allow patients to have a VBAC.
Rationale 4:
The incidence of uterine rupture is 0.9%. Women who have a successful VBAC have lower
incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
