Maternal-Newborn chapter 15
test bank LATEST 2024
ACTUAL EXAM COMPLETE
400 QUESTIONS AND
CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS)
|ALREADY GRADED A+
Which nursing diagnosis would take
priority in the care of a primipara patient
with no visible support person in
attendance? The patient has entered the
second stage of labor after a first stage
of labor lasting 4 hours.
A: fluid volume deficit (FVD) related to
fluid loss during labor and birth process
B: fatigue related to length of labor
requiring increased energy expenditure
C: acute pain related to increased
intensity of contractions
D: anxiety related to imminent birth
process - ANSWER-D: anxiety related to
imminent birth process
RATIONALE: A primipara is experiencing
the birthing event for the first time and
may experience anxiety due to fear of
the unknown. It would be important to
recognize this because the patient is
alone in the labor-birth room and will
need additional support and
reassurance. Although FVD may occur as
a result of fluid loss, prospective
management of labor patients includes
the use of parenteral fluid therapy; the
patient should be monitored for FVD
and, if symptoms warrant, receive
intervention. Because the patient has
been in labor for 4 hours, this is not
considered to be a prolonged labor
pattern for a primipara patient. Although
the patient may be tired, this nursing
diagnosis would not be a priority unless
there were other symptoms manifested.
The patient is entering the second stage
of labor; therefore she will be allowed to
push with contractions. In terms of pain
management, medication will not be
administered at this time because of
imminent birth.
Which comfort measure should the
nurse utilize a laboring woman to relax?
A: recommend frequent position
changes
B: palpate her filling bladder every 15
minutes
C: offer warm wet cloths to use on the
client's face and neck
D: keep the room lights lit so the client
and her coach can see everything -
ANSWER-A: recommend frequent
position changes
RATIONALE: Frequent maternal position
changes reduce the discomfort from
constant pressure and promote fetal
descent. A full bladder intensifies labor
pain. The bladder should be emptied
every 2 hours. Women in labor become
very hot and perspire. Cool cloths will
provide greater relief. Soft indirect
lighting is more soothing than irritating
bright lights.
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