Chapter 16: Nursing Care of the Family During Labor and Birth Perry: Maternal Child Nursing Care, 6th Edition

Chapter 16:
Nursing Care of
the Family During
Labor and Birth
Perry: Maternal
Child Nursing
Care, 6th Edition
1. The nurse recognizes that a woman is in true
labor when she states:
a. "I passed some thick, pink mucus when I
urinated this morning."
b. "My bag of waters just broke."
c. "The contractions in my uterus are getting
stronger and closer together."
d. "My baby dropped, and I have to urinate more
frequently now." - ANSWER-ANS: C
Regular, strong contractions with the presence of
cervical change indicate that the woman is
experiencing true labor. Loss of the mucous plug
(operculum) often occurs during the first stage of
labor or before the onset of labor, but it is not the
indicator of true labor. Spontaneous rupture of
membranes often occurs during the first stage of
labor, but it is not the indicator of true labor. The
presenting part of the fetus typically becomes
engaged in the pelvis at the onset of labor, but
this is not the indicator of true labor.
2. The nurse teaches a pregnant woman about the
characteristics of true labor contractions. The
nurse evaluates the woman's understanding of the
instructions when she states, "True labor
contractions will:
a. subside when I walk around."
b. cause discomfort over the top of my uterus."
c. continue and get stronger even if I relax and
take a shower."
d. remain irregular but become stronger." -
ANSWER-ANS: C
True labor contractions occur regularly, becoming
stronger, lasting longer, and occurring closer
together. They may become intense during
walking and continue despite comfort measures.
Typically true labor contractions are felt in the
lower back, radiating to the lower portion of the
abdomen. During false labor, contractions tend to
be irregular and felt in the abdomen above the
navel. Typically the contractions often stop with
walking or a change of position.
3. When a nulliparous woman telephones the
hospital to report that she is in labor, the nurse
initially should:
a. tell the woman to stay home until her
membranes rupture.
b. emphasize that food and fluid intake should
stop.
c. arrange for the woman to come to the hospital
for labor evaluation.
d. ask the woman to describe why she believes she
is in labor. - ANSWER-ANS: D
Assessment begins at the first contact with the
woman, whether by telephone or in person. By
asking the woman to describe her signs and
symptoms, the nurse can begin the assessment
and gather data. The amniotic membranes may or
may not spontaneously rupture during labor. The
patient may be instructed to stay home until the
uterine contractions become strong and regular.
The nurse may want to discuss the appropriate
oral intake for early labor such as light foods or
clear liquids, depending on the preference of the
patient or her primary health care provider.
Before instructing the woman to come to the
hospital, the nurse should initiate the assessment
during the telephone interview.
4. When planning care for a laboring woman
whose membranes have ruptured, the nurse
recognizes that the woman's risk for
_________________________ has increased.
a. intrauterine infection
b. hemorrhage
c. precipitous labor
d. supine hypotension - ANSWER-ANS: A
When the membranes rupture, microorganisms
from the vagina can ascend into the amniotic sac
and cause chorioamnionitis and placentitis.
Rupture of membranes (ROM) is not associated
with fetal or maternal bleeding. Although ROM
may increase the intensity of contractions and
facilitate active labor, it does not result in
precipitous labor. ROM has no correlation with
supine hypotension.