Labor Pain Quiz
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On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, –1. What is the correct interpretation of the data?
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A. The fetal presenting part is 1 cm above the ischial spines
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B. Effacement is 4 cm from completion.
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C. Dilation is 50% completed.
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D. The fetus has achieved passage through the ischial spines.
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Do you know everything about labor pain? Take this labor pain quiz to see what knowledge you have and what more you need to know. If you are preparing for a nursing exam, it will be a helpful practice quiz. It will not only test your knowledge but even if you miss out on something. There will be a quick See moreanswer to help you. You must give this quiz a try. All the best! You can share the quiz with others too.
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- 2.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a “dry labor.” Which of the following responses by the nurse would be MOST appropriate? THIS MAY NOT BE ON THE EXAM
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. “The amniotic fluid provides only minimal lubrication for the labor process.”
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“The amniotic sac may impede the progress of labor and is often ruptured artificially.”
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“Labor is only slightly more difficult with early rupture of the amniotic sac.”
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“Because there is limited amniotic fluid, additional fluids will be supplied.”
Correct Answer
A. “The amniotic sac may impede the progress of labor and is often ruptured artificially.”Explanation
Correct—sometimes done to assist or induce laborRate this question:
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- 3.
A primipara is admitted in early labor, and her membranes rupture. Which of the following assessments by the nurse are MOST important.
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Determine the pH of the amniotic fluid.
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Evaluate the mother’s blood pressure.
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Check the monitor for decelerations.
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Assess for a prolapsed cord.
Correct Answer
A. Assess for a prolapsed cord.Explanation
A. amniotic fluid is important to check to differentiate it from the urine; pH will be acidic if it is urine
B. Mother’s blood pressure is not affected by rupture of the membranes
C. Nurse should look for variable decelerations if the cord is prolapsed
D. Correct—initial assessment is to check for a prolapsed cordRate this question:
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- 4.
During the fourth stage of labor, the nurse should palpate the fundus.
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Three cm below the umbilicus
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At the umbilicus
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Two cm above the umbilicus
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to the right of the umbilicus
Correct Answer
A. At the umbilicusExplanation
B uterus is normally contracted and palpable at the umbilicus.Rate this question:
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- 5.
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman’s husband is at her side and has been coaching her according to exercises they learned in natural childbirth classes. Suddenly the woman begins to shake and screams, “I can't stand this anymore!” Should the nurse encourage the husband to? MAY NOT BE ON THE TEST.
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Instruct his wife to use shallow respirations during the contractions.
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Offer his wife ice chips or sips of water to distract her from the pain.
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Stroke his wife’s abdomen between contractions.
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Review with his wife the breathing pattern needed at each stage of labor.
Correct Answer
A. Instruct his wife to use shallow respirations during the contractions.Explanation
A: Entering transition phase of first stage of labor, slow, shallow breaths needed (pant breathing) *pg. 464 table 18-5Rate this question:
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- 6.
A 28-year-old woman at 39 weeks gestation in active labor screams, “I have to push, I have to push.” The nurse notes that the client is 8 cm dilated. Should the nurse?
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Instruct the client to take a deep breath and bear down.
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Apply gentle but firm fundal pressure to the client’s abdomen.
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Coach the client in relaxation techniques.
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Tell the client to pant with pursed lips.
Correct Answer
A. Tell the client to pant with pursed lips.Explanation
Answer D: describes transition phase of labor, breathing technique allows the patient to control
pain and urge to push and promotes adequate oxygenation of fetus LOOK AT PG. 464 table 18-5Rate this question:
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- 7.
The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching? THIS MAY NOT BE ON THE EXAM
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“I will note an increase in fetal movement.”
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“I may feel a gush of fluid run down my legs.”
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“I may see some blood in my vaginal discharge.”
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“I may experience a low backache.”
Correct Answer
A. “I will note an increase in fetal movement.”Explanation
Answer: A . usually, movement decreases with the onset of laborRate this question:
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- 8.
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
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Discontinue the infusion
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Turn the client to the left side
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Change the fluids to LR
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Increase the IV flow rate
Correct Answer
A. Discontinue the infusionExplanation
A : will decrease contractions and thus possibly remove uterine pressure to the fetus,
which possibly cause of decelerationRate this question:
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- 9.
During a nonstress test (NST), the nurse observes several late decelerations. Which of the following nursing actions is MOST appropriate? THIS MAY NOT BE ON THE EXAM
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Reposition the client on her right side.
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Notify the physician for further evaluation.
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Document these results in the nurse's notes.
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Stop the oxytocin (Pitocin) immediately.
Correct Answer
A. Notify the physician for further evaluation.Explanation
A. does not resolve the immediate problem
B. correct— the appearance of any decelerations of the fetal heart rate (FHR) during NST should
be immediately evaluated by the physician
C does not resolve the immediate problem
D. incorrect for this test; oxytocin (Pitocin) is not used for the nonstress testRate this question:
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- 10.
The newborn infant of an HIV-positive mother is admitted to the nursery. Which of the following would the nurse include in the plan of care?
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Standard precautions.
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. Testing for HIV.
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Transfer to an acute care nursery facility.
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Request AZT from the pharmacy.
Correct Answer
A. Standard precautions.Explanation
correct–provides immediate protective care for the staff * pg.. 643Rate this question:
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- 11.
At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when the nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as?
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5
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7
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9
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10
Correct Answer
A. 9Explanation
Answer: C. The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color since he exhibits acrocyanosis.Rate this question:
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- 12.
Which of the following rationales best explains why a pregnant client should lie on her left side when resting or sleeping in the later stages of pregnancy?
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To facilitate digestion
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To facilitate bladder emptying
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To prevent compression of vena cava
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. to avoid fetal anomalies
Correct Answer
A. To prevent compression of vena cavaExplanation
3. to prevent compression of the vena cava
the weight of the preg uterus is sufficiently heavy to compress the vena cava, which could impair blood flow to the uterus, possibly decreasing oxygen to the fetus. The side-lying position hasn't been shown to prevent fetal anomalies nor bladder emptying and or digestionRate this question:
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- 13.
A woman with a term, uncomplicated pregnancy comes into L&D in early labor, saying that she thinks her water broke. Which action should the nurse take?
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Prep the woman for delivery
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Note color, amt, and odor of the fluid
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Immediately contact doctor
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Collect a sample of fluid for microbial analysis
Correct Answer
A. Note color, amt, and odor of the fluidExplanation
Noting the color, amount, and odor of the fluid as well as the time of the rupture, will help guide the nurse in her next action. There's no need to call the doctor to prep the client for delivery if the fluid is clear and delivery isn't imminent. ROM isn't unusual in the early stages of labor. Fluid collection for microbe analysis isn't routine, and there's no concern for infection/maternal fever.Rate this question:
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- 14.
A client at 42 weeks gest is 3cm dilated, 30% effaced, with membranes intact, and the fetus at +2 station. FHR is at 140-150 bpm. After 2 hours, the nurse notes on the EFM that, for the past 10 min, the FHR ranged from 160-190bpm. The client states that her baby has been extremely active. UCs are strong, occurring every 3-4 min. and lasting 40-60 sec. Which of the following findings would indicate fetal hypoxia?
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Abnormally long UCs
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Abnormally strong uterine intensity
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Excessively frequent contractions with rapid fetal movement
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Excessive fetal activity and fetal tachycardia
Correct Answer
A. Excessive fetal activity and fetal tachycardiaExplanation
4. Excessive fetal activity and fetal tachycardia and excessive fetal activity are the FIRST SIGNS OF FETAL HYPOXIA. The duration of UCs is w/in normal limits.
Uterine intensity can be mild-strong and still be w/in normal limits.
The frequency of contractions is w/in normal limits for the active phase of labor.Rate this question:
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- 15.
The cervix of a 26-year-old primigravida in labor is 5cm dilated and 75% effaced, and the fetus is at 0 stations. The doctor prescribes a regional epidural block. Into which of the following positions should the nurse place the client when the epidural is admin?
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Lithotomy
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Supine
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Prone
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Lateral
Correct Answer
A. LateralExplanation
The client should be placed on her left side or sitting upright, with her shoulders parallel and legs slightly flexed. Her back shouldn't be flexed because this increases the possibility that the dura may be punctured, and the anesthetic will accidentally be given as spinal, not epidural, anesthesia.Rate this question:
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- 16.
Which of the following terms is used to describe the thinning and shortening of the cervix that occurs just before and during labor?
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Ballottement
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Dilation
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Effacement
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Muliparous
Correct Answer
A. EffacementExplanation
Effacement is cervical shortening and thinning, while dilation is widening of the cervix. Both facilitate opening the cervix in prep for delivery. Ballottement is the ability of another individual to move the fetus by externally manipulating the maternal abdomen. A ballotable fetus hasn't yet engaged in the maternal pelvis. Multiparous refers to a woman who has had previous live births.Rate this question:
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- 17.
Which of the following fetal positions is most favorable for birth?
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Vertex (Cephalic, Longitudinal Lie)
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Transverse lie
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Frank breech presentation
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None of the above
Correct Answer
A. Vertex (Cephalic, Longitudinal Lie)Explanation
The most favorable fetal position for birth is the Vertex (Cephalic, Longitudinal Lie) position. In this position, the baby's head is down, facing the birth canal, which allows for a smoother and easier delivery. This position is considered ideal because it aligns the baby's head with the mother's pelvis, allowing for a more efficient descent through the birth canal. Transverse lie refers to a position where the baby is lying horizontally across the uterus, which can make vaginal delivery difficult or impossible. Frank breech presentation refers to a position where the baby's buttocks are down and the legs are straight up, which also presents challenges for vaginal delivery. Therefore, the Vertex position is the most favorable for birth.Rate this question:
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- 18.
Which of the following nursing actions is required before a client in labor receives an epidural?
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Give a fluid bolus of 500 ml
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Check for maternal pupil dilation
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assess maternal reflexes
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Assess maternal gait
Correct Answer
A. Give a fluid bolus of 500 mlExplanation
Give a fluid bolus of 500 ml. One of the major adverse effects of epidural admin is hypotension; therefore, a 500ml fluid bolus is usually admin to help prevent hypotension in the client who wishes to receive an epidural for pain relief. Assessments of maternal reflexes, pupil response, and gait aren't necessary.Rate this question:
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- 19.
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to:
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Maternal hyperthyroidism.
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Initiation of epidural anesthesia that resulted in maternal hypotension
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Maternal infection accompanied by fever.
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Alteration in maternal position from semirecumbent to lateral.
Correct Answer
A. Initiation of epidural anesthesia that resulted in maternal hypotensionExplanation
Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure.Rate this question:
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- 20.
On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should:
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Describe the finding in the nurse's notes.
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Reposition the woman onto her side.
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Call the physician for instructions.
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Administer oxygen at 8 to 10 L/min with a tight face mask.
Correct Answer
A. Describe the finding in the nurse's notes.Explanation
An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix.Rate this question:
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- 21.
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? THIS MAY NOT BE ON THE EXAM
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FHR does not change as a result of fetal activity.
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Average baseline rate ranges between 100 and 140 beats/min.
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Mild late deceleration patterns occur with some contractions.
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Variability averages between 6 to 10 beats/min.
Correct Answer
A. Variability averages between 6 to 10 beats/min.Explanation
Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.Rate this question:
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- 22.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's immediate action would be to:
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Change the woman's position.
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Stop the Pitocin.
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Elevate the woman's legs.
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Administer oxygen via a tight mask at 8 to 10 L/min.
Correct Answer
A. Stop the Pitocin.Explanation
Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin that stimulates the uterus to contract.Rate this question:
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- 23.
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be:
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Presence of soft, non-tender colostrum
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Leakage of milk at let-down.
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Swollen, warm, and tender on palpation.
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A few blisters and a bruise on each areola.
Correct Answer
A. Presence of soft, non-tender colostrumExplanation
Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.Rate this question:
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- 24.
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of the midline. The nurse should:
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Massage the fundus.
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Administer Methergine, 0.2 mg PO, that has been ordered prn.
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Assist the woman in emptying her bladder.
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Recognize this as an expected finding during the first 24 hours following birth.
Correct Answer
A. Assist the woman in emptying her bladder.Explanation
The findings indicate a full bladder, which pushes the uterus up and to the right or left of the midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow.Rate this question:
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- 25.
Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours’ postpartum?
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Postural hypotension
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Temperature of 100.4° F
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Bradycardia—pulse rate of 55 beats/min
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Pain in left calf with dorsiflexion of left foot
Correct Answer
A. Pain in left calf with dorsiflexion of left footExplanation
These findings indicate a positive Homan’s sign and are suggestive of thrombophlebitis and should be investigated.Rate this question:
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- 26.
The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:
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Place her on a bedpan to empty her bladder
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Massage her fundus.
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Call the physician.
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Administer Methergine, 0.2 mg IM, which has been ordered prn.
Correct Answer
A. Massage her fundus.Explanation
A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm.Rate this question:
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- 27.
Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:
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Uses soap and warm water to wash the vulva and perineum.
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Washes from symphysis pubis back to episiotomy.
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Changes her perineal pad every 2 to 3 hours.
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Uses the peri bottle to rinse upward into her vagina.
Correct Answer
A. Uses the peri bottle to rinse upward into her vagina.Explanation
The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.Rate this question:
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- 28.
Which measure would be least effective in preventing postpartum hemorrhage? THIS MAY NOT BE ON THE EXAM
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Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered
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Encourage the woman to void every 2 hours
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Massage the fundus every hour for the first 24 hours following birth
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Teach the woman the importance of rest and nutrition to enhance healing
Correct Answer
A. Massage the fundus every hour for the first 24 hours following birthExplanation
The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.Rate this question:
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- 29.
The nurse notes that when the newborn is placed on the scale, he immediately abducts and extends his arms, and his fingers fan out with the thumb and forefinger, forming a "C." This response is known as a:
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Tonic neck reflex.
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Moro reflex.
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Cremasteric reflex
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Babinski reflex.
Correct Answer
A. Moro reflex.Explanation
These actions show the Moro reflex * table 24-1 pg. 622Rate this question:
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- 30.
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?
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Apical heart rate of 90 beats/min, slightly irregular, when awake and active
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Acrocyanosis
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Harlequin color sign
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Weight loss represents 5% of the newborn's birth weight
Correct Answer
A. Apical heart rate of 90 beats/min, slightly irregular, when awake and activeExplanation
The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds.Rate this question:
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- 31.
When caring for a newborn, the nurse must be alert for signs of cold stress, including:
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Decreased activity level.
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Increased respiratory rate.
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Hyperglycemia
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Shivering.
Correct Answer
A. Increased respiratory rate.Explanation
An increased respiratory rate is a sign of cold stress in the newborn.Rate this question:
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- 32.
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since a large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:
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Telling the mother not to worry since all breastfed babies have this type of stool.
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Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.
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Asking the mother what she ate at her last meal.
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Suggesting that the mother ask her pediatrician to explain her newborn stool patterns to her.
Correct Answer
A. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.Explanation
At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns.Rate this question:
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- 33.
Vitamin K is given to the newborn to:
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Reduce bilirubin levels.
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Increase the production of red blood cells
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Enhance the ability of blood to clot.
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Stimulate the formation of surfactant.
Correct Answer
A. Enhance the ability of blood to clot.Explanation
Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors.Rate this question:
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- 34.
The nurse is making rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. Should the nurse?
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Put the infant to the woman�s breast.
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Encourage the woman to drink warm oral fluids.
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Check the woman's pulse and respirations
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Continue to monitor the firmness of the uterus.
Correct Answer
A. Put the infant to the woman�s breast.Explanation
1) correct–implementation causes a natural surge of oxytocin that results in contraction of the uterus (2) implementation has no effect on contraction of the uterus (3) assessment is not the best action. The situation does not suggest that patient is in shock (4) assessment, needs manual massage or release of natural oxytocin to contract the uterusRate this question:
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- 35.
The nurse is caring for clients in the postpartum unit. A client receiving heparin for the treatment of deep vein thrombosis (DVT) says to the nurse, “I am so upset that I can’t breastfeed my infant.” Which of the following statements made by the nurse is BEST?
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“You will be able to breastfeed your baby.”
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“You will be able to breastfeed your baby.”
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“We will check your baby’s clotting times.”
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“We will give the baby protamine sulfate.”
Correct Answer
A. “You will be able to breastfeed your baby.”Explanation
Correct—heparin not transmitted in breast milk; breastfeeding considered safe (2) yes/no question, nontherapeutic (3) heparin not transmitted to the infant, only concerned about the mother’s PTT (4) is the antidote for heparin, not required * look at pg 585 right under the Medication guide.Rate this question:
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Aug 22, 2023Quiz Edited by
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Oct 27, 2012Quiz Created by
Nursingstudent71
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