18.8.1: Review Questions
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Review Questions
1 .
What procedure might the nurse perform to determine the presentation of the fetus?
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vaginal exam
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ultrasound
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palpation of contractions
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laboring person interview
2 .
During the first stage of labor, what is the primary goal of nursing care in the early phase?
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Administer pain medication.
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Monitor fetal heart rate continuously.
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Promote relaxation and provide comfort measures.
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Prepare for imminent delivery.
3 .
What assessment findings are essential components of obstetric triage? Select all that apply.
- history and physical
- fetal monitoring
- EDD
- 24-hour diet recall
4 .
A pregnant person in the first stage of labor experiences rupture of membranes. What is the nurse’s priority action?
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Administer an epidural for pain relief.
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Start an IV line and administer antibiotics.
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Document the FHR and time and characteristics of the amniotic fluid.
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Prepare for immediate delivery.
5 .
What assessment data are collected to assess progress during the second stage of labor?
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fetal heart rate
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fetal descent
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bearing-down effort
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contraction strength
6 .
In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
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every 5 minutes with contractions
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at least every 30 minutes
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every 5–15 minutes
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only when the physician orders assessment
7 .
A laboring person on oxytocin for induction of labor should have continuous monitoring of the fetal heart rate. How often should the nurse assess the fetal heart rate?
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every 30 minutes
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every 15 minutes
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every 5 minutes
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every 1 hour
8 .
What is the primary goal of fetal heart rate monitoring during the second stage of labor?
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to predict when to bear down during contractions
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to determine the strength of the uterine contractions
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to evaluate fetal well-being
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to monitor vital signs of the birthing person
9 .
During open glottis pushing, what is the laboring person instructed to do?
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hold their breath and push for 10 seconds during each contraction
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push spontaneously while exhaling during contractions
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exhale slowly during contractions without pushing
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perform deep breathing exercises between contractions
10 .
Which statement accurately describes the importance of birthing person position changes during the second stage of labor?
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Position changes have an impact on fetal descent.
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Position changes can lead to support person stress.
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Fetal descent is solely determined by uterine contractions.
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Maintaining a supine position is the safest option.
11 .
How long should clamping of the cord be delayed in an uncomplicated delivery to increase the newborn’s hemoglobin levels and improve circulation?
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30–60 seconds
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15–30 seconds
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30 seconds
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Delayed cord clamping is not recommended.
12 .
A birthing person who delivered a newborn vaginally is receiving care in the labor and birth unit. The health-care provider diagnosed a retained placenta. What is the primary risk associated with a retained placenta?
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neonatal jaundice
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postpartum hemorrhage
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delayed bonding
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postpartum anemia
13 .
A nurse is assisting with a vaginal birth and is monitoring for signs of placental separation. What is the most reliable clinical indicator that the placenta has separated?
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a gush of clear amniotic fluid
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uterine contractions every 2 to 3 minutes
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lengthening of the umbilical cord
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maternal report of intense pain
14 .
During a vaginal birth, a birthing person experienced a second-degree perineal laceration. What is a characteristic of a second-degree laceration?
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It involves only the vaginal mucosa.
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It extends through the vaginal and perineal muscles.
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It is the least severe type of laceration.
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It does not require suturing.
15 .
A nurse is administering an uterotonic medication to a birthing person who has just delivered the placenta. Which uterotonic medication is commonly used to prevent postpartum hemorrhage and promote uterine contractions?
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oxytocin (Pitocin)
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fentanyl (Sublimaze)
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epinephrine (Adrenaline)
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lorazepam (Ativan)
16 .
During the postpartum period, a nurse is caring for a birthing person who is receiving uterotonic medications. The nurse’s assessment reveals a boggy and enlarged uterus. What is the nurse’s immediate action?
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Document the findings as normal.
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Continue to administer the uterotonic medication.
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Perform fundal massage to promote uterine firmness.
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Administer an analgesic for the birthing person’s pain.
17 .
How often should the nurse assess the blood pressure, pulse, and respirations of the birthing person during the first hour of the fourth stage of labor?
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every 15 minutes
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every 30 minutes
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not until after the first hour
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once, then hourly
18 .
In what ways can the nurse support involution of the uterus in the fourth stage of labor? Select all that apply.
- uterotonics
- encouraging the birthing person to urinate
- fundal massage
- providing the baby a bottle so that the birthing person can rest
- delaying breast-feeding
19 .
A nurse is educating a birthing person about the benefits of skin-to-skin contact with their newborn immediately after birth. The nurse explains that this practice has numerous advantages. Which of the following benefits is NOT typically associated with skin-to-skin contact?
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improved bonding between parent and baby
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enhanced thermoregulation for the newborn
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decreased risk of neonatal infections
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accelerated uterine involution for the birthing person
20 .
During the fourth stage of labor, a nurse assesses the perineum of a birthing person who had a vaginal birth. What is the primary purpose of this assessment?
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to evaluate the birthing person’s readiness for discharge
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to ensure the birthing person can ambulate safely
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to detect any signs of perineal trauma
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to assess the status of cervical dilation
21 .
A nurse is caring for a postpartum person during the fourth stage of labor. The nurse is assessing uterine involution to ensure that the uterus is returning to its prepregnancy size and position. Which finding is indicative of normal uterine involution during this stage?
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Uterus is palpable at the level of the umbilicus.
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Uterine fundus is firm, at the level of the umbilicus.
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Uterus is displaced to the right side of the abdomen.
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Uterine fundus is above the level of the umbilicus.