Labor Pain Quiz

1. Which of the following fetal positions is most favorable for birth?

Vertex (Cephalic, Longitudinal Lie)

Transverse lie

Frank breech presentation

None of the above

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.

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.

2. 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:

Telling the mother not to worry since all breastfed babies have this type of stool.

Asking the mother what she ate at her last meal.

Suggesting that the mother ask her pediatrician to explain her newborn stool patterns to her.

At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns.

Explanation

At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns.

3. 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?

To facilitate digestion

To facilitate bladder emptying

To prevent compression of vena cava

. to avoid fetal anomalies

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 digestion

Explanation

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 digestion

4. Which of the following terms is used to describe the thinning and shortening of the cervix that occurs just before and during labor?

Ballottement

Dilation

Effacement

Muliparous

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.

Explanation

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.

5.

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:

Change the woman's position.

Stop the Pitocin.

Elevate the woman's legs.

Administer oxygen via a tight mask at 8 to 10 L/min.

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.

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.

6. Vitamin K is given to the newborn to:

Reduce bilirubin levels.

Increase the production of red blood cells

Enhance the ability of blood to clot.

Stimulate the formation of surfactant.

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.

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.

7. 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?

A. The fetal presenting part is 1 cm above the ischial spines

B. Effacement is 4 cm from completion.

C. Dilation is 50% completed.

D. The fetus has achieved passage through the ischial spines.

Rationale: Station of –1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. * pg. 380

Explanation

Rationale: Station of –1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. * pg. 380

8. 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?

Prep the woman for delivery

Note color, amt, and odor of the fluid

Immediately contact doctor

Collect a sample of fluid for microbial analysis

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.

Explanation

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.

9. 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:

Place her on a bedpan to empty her bladder

Massage her fundus.

Call the physician.

Administer Methergine, 0.2 mg IM, which has been ordered prn.

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.

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.

10. 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:

Tonic neck reflex.

Moro reflex.

Cremasteric reflex

Babinski reflex.

These actions show the Moro reflex * table 24-1 pg. 622

Explanation

These actions show the Moro reflex * table 24-1 pg. 622

11. 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:

Presence of soft, non-tender colostrum

Leakage of milk at let-down.

Swollen, warm, and tender on palpation.

A few blisters and a bruise on each areola.

Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.

Explanation

Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.

12. 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

Discontinue the infusion

Turn the client to the left side

Change the fluids to LR

Increase the IV flow rate

A : will decrease contractions and thus possibly remove uterine pressure to the fetus,
which possibly cause of deceleration

Explanation

A : will decrease contractions and thus possibly remove uterine pressure to the fetus,
which possibly cause of deceleration

13. 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:

Massage the fundus.

Administer Methergine, 0.2 mg PO, that has been ordered prn.

Assist the woman in emptying her bladder.

Recognize this as an expected finding during the first 24 hours following birth.

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.

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.

14. A primipara is admitted in early labor, and her membranes rupture. Which of the following assessments by the nurse are MOST important.

Determine the pH of the amniotic fluid.

Evaluate the mother’s blood pressure.

Check the monitor for decelerations.

Assess for a prolapsed cord.

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 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 cord

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?

Lithotomy

Supine

Prone

Lateral

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.

Explanation

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.

16. 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?

5

7

9

10

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.

Explanation

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.

17. Which of the following nursing actions is required before a client in labor receives an epidural?

Give a fluid bolus of 500 ml

Check for maternal pupil dilation

Assess maternal reflexes

Assess maternal gait

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.

Explanation

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.

18. 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:

Maternal hyperthyroidism.

Initiation of epidural anesthesia that resulted in maternal hypotension

Maternal infection accompanied by fever.

Alteration in maternal position from semirecumbent to lateral.

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.

Explanation

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.

19. 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?

Abnormally long UCs

Abnormally strong uterine intensity

Excessively frequent contractions with rapid fetal movement

Excessive fetal activity and fetal tachycardia

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.

Explanation

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.

20. During the fourth stage of labor, the nurse should palpate the fundus.

Three cm below the umbilicus

At the umbilicus

Two cm above the umbilicus

To the right of the umbilicus

B uterus is normally contracted and palpable at the umbilicus.

Explanation

B uterus is normally contracted and palpable at the umbilicus.

21. 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?

Standard precautions.

. Testing for HIV.

Transfer to an acute care nursery facility.

Request AZT from the pharmacy.

correct–provides immediate protective care for the staff * pg.. 643

Explanation

correct–provides immediate protective care for the staff * pg.. 643

22. 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

. “The amniotic fluid provides only minimal lubrication for the labor process.”

“The amniotic sac may impede the progress of labor and is often ruptured artificially.”

“Labor is only slightly more difficult with early rupture of the amniotic sac.”

“Because there is limited amniotic fluid, additional fluids will be supplied.”

Correct—sometimes done to assist or induce labor

Explanation

Correct—sometimes done to assist or induce labor

23. What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?

Apical heart rate of 90 beats/min, slightly irregular, when awake and active

Acrocyanosis

Harlequin color sign

Weight loss represents 5% of the newborn's birth weight

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.

Explanation

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.

24.

Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum?

Postural hypotension

Temperature of 100.4° F

Bradycardia—pulse rate of 55 beats/min

Pain in left calf with dorsiflexion of left foot

These findings indicate a positive Homan’s sign and are suggestive of thrombophlebitis and should be investigated.

Explanation

These findings indicate a positive Homan’s sign and are suggestive of thrombophlebitis and should be investigated.

25. 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.

Instruct his wife to use shallow respirations during the contractions.

Offer his wife ice chips or sips of water to distract her from the pain.

Stroke his wife’s abdomen between contractions.

Review with his wife the breathing pattern needed at each stage of labor.

A: Entering transition phase of first stage of labor, slow, shallow breaths needed (pant breathing) *pg. 464 table 18-5

Explanation

A: Entering transition phase of first stage of labor, slow, shallow breaths needed (pant breathing) *pg. 464 table 18-5

26. 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?

“You will be able to breastfeed your baby.”

“We will check your baby’s clotting times.”

“We will give the baby protamine sulfate.”

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.

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.

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:

Uses soap and warm water to wash the vulva and perineum.

Washes from symphysis pubis back to episiotomy.

Changes her perineal pad every 2 to 3 hours.

Uses the peri bottle to rinse upward into her vagina.

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.

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.

28. The nurse is making rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. Should the nurse?

Put the infant to the woman�s breast.

Encourage the woman to drink warm oral fluids.

Check the woman's pulse and respirations

Continue to monitor the firmness of the uterus.

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 uterus

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 uterus

29. 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

“I will note an increase in fetal movement.”

“I may feel a gush of fluid run down my legs.”

“I may see some blood in my vaginal discharge.”

“I may experience a low backache.”

Answer: A . usually, movement decreases with the onset of labor

Explanation

Answer: A . usually, movement decreases with the onset of labor

30. Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? THIS MAY NOT BE ON THE EXAM

FHR does not change as a result of fetal activity.

Average baseline rate ranges between 100 and 140 beats/min.

Mild late deceleration patterns occur with some contractions.

Variability averages between 6 to 10 beats/min.

Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.

Explanation

Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.

31. 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?

Instruct the client to take a deep breath and bear down.

Apply gentle but firm fundal pressure to the client’s abdomen.

Coach the client in relaxation techniques.

Tell the client to pant with pursed lips.

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 18-5

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 18-5

32. 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:

Describe the finding in the nurse's notes.

Reposition the woman onto her side.

Call the physician for instructions.

Administer oxygen at 8 to 10 L/min with a tight face mask.

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.

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.

33. 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

Reposition the client on her right side.

Notify the physician for further evaluation.

Document these results in the nurse's notes.

Stop the oxytocin (Pitocin) immediately.

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 test

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 test

34. Which measure would be least effective in preventing postpartum hemorrhage? THIS MAY NOT BE ON THE EXAM

Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered

Encourage the woman to void every 2 hours

Massage the fundus every hour for the first 24 hours following birth

Teach the woman the importance of rest and nutrition to enhance healing

The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.

Explanation

The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.

35. When caring for a newborn, the nurse must be alert for signs of cold stress, including:

Decreased activity level.

Increased respiratory rate.

Hyperglycemia

Shivering.

An increased respiratory rate is a sign of cold stress in the newborn.

Explanation

An increased respiratory rate is a sign of cold stress in the newborn.