Maternal And Child Health Nursing NCLEX Quiz 31

1. The first thing that a nurse must ensure when the baby's head comes out is

The cord is intact

No part of the cord is encircling the baby’s neck

The cord is still attached to the placenta

The cord is still pulsating

The nurse should check right away for possible cord coil around the neck because if it is present. the baby can be strangulated by it and the fetal head will have difficulty being delivered.

Explanation

The nurse should check right away for possible cord coil around the neck because if it is present. the baby can be strangulated by it and the fetal head will have difficulty being delivered.

2. The normal umbilical cord is composed of:

2 arteries and 1 vein

2 veins and 1 artery

2 arteries and 2 veins

None of the above

The umbilical cord is composed of 2 arteries and 1 vein.

Explanation

The umbilical cord is composed of 2 arteries and 1 vein.

3. The mechanisms involved in fetal delivery is

Descent. extension. flexion. external rotation

Descent. flexion. internal rotation. extension. external rotation

Flexion. internal rotation. external rotation. extension

Internal rotation. extension. external rotation. flexion

The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. Flexion. internal rotation. and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus.

Explanation

The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. Flexion. internal rotation. and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus.

4. The second stage of labor begins with ___ and ends with __?

Begins with full dilatation of cervix and ends with delivery of placenta

Begins with true labor pains and ends with delivery of baby

Begins with complete dilatation and effacement of cervix and ends with delivery of baby

Begins with passage of show and ends with full dilatation and effacement of cervix

Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of the baby. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix.

Explanation

Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of the baby. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix.

5. The following are correct statements about false labor EXCEPT

The pain is irregular in intensity and frequency.

The duration of contraction progressively lengthens over time

There is no bloody vaginal discharge

The cervix is still closeD.

In false labor. the contractions remain to be irregular in intensity and duration while in true labor. the contractions become stronger. longer and more frequent.

Explanation

In false labor. the contractions remain to be irregular in intensity and duration while in true labor. the contractions become stronger. longer and more frequent.

6. At what stage of labor and delivery does a primigravida differ mainly from a multigravida?

Stage 1

Stage 2

Stage 3

Stage 4

In stage 1 during a normal vaginal delivery of a vertex presentation. the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor.

Explanation

In stage 1 during a normal vaginal delivery of a vertex presentation. the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor.

7. When doing perineal care in preparation for delivery. the nurse should observe the following EXCEPT

Use up-down technique with one stroke

Clean from the mons veneris to the anus

Use mild soap and warm water

Paint the inner thighs going towards the perineal area

Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. The perineal area is the one being prepared for the delivery and must be kept clean

Explanation

Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. The perineal area is the one being prepared for the delivery and must be kept clean

8. The passageway in labor and delivery of the fetus include the following EXCEPT

Distensibility of lower uterine segment

Cervical dilatation and effacement

Distensibility of vaginal canal and introitus

Flexibility of the pelvis

The pelvis is a bony structure that is part of the passageway but is not flexible. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus.

Explanation

The pelvis is a bony structure that is part of the passageway but is not flexible. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus.

9. What are the important considerations that the nurse must remember after the placenta is delivered? Select all that apply

Check if the placenta is complete including the membranes

Check if the cord is long enough for the baby

Check if the umbilical cord has 3 blood vessels

Check if the cord has a meaty portion and a shiny portion

The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete. Also. the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels: 1 vein and 2 arteries.

Explanation

The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete. Also. the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels: 1 vein and 2 arteries.

Submit

10. To ensure that the baby will breathe as soon as the head is delivered. the nurse's priority action is to

Suction the nose and mouth to remove mucous secretions

Slap the baby’s buttocks to make the baby cry

Clamp the cord about 6 inches from the base

Check the baby’s color to make sure it is not cyanotic

Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that may be present allowing for better breathing. Also. if mucus is in the nose and mouth. aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby’s head has come out as given in the situation.)

Explanation

Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that may be present allowing for better breathing. Also. if mucus is in the nose and mouth. aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby’s head has come out as given in the situation.)