Chapter 14 Nursing Management During Labor and Birth

Chapter 14 Nursing Management During Labor and Birth Test Bank for Maternity and Pediatric Nursing, 4th Edition by Ricci, Kyle, And Carman

1. A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? A. butorphanol B. fentanyl C. naloxone D. promethazine Answer: C Rationale: Naloxone is an opioid antagonist used to reverse the eafbfierbc.tcsomo/fteostpioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid. Question format: Multiple Choice Chapter 14: Nursing Management During Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Paren abt ie rbr .a c l omT /h tee st rapies Reference: p. 489 2. A client's membranes spontaneously ruptured, as evidenced byabairbg.cuosmh/teosft clear fluid with a contraction. What would the nurse do next? A. Check the fetal heart rate. B. Perform a vaginal exam. C. Notify the primary care provider immediately. D. Change the linen saver pad. Answer: A Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progres ab s i i ro b.n coo mf /te la stbor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified. Question format: Multiple Choice Chapter 14: Nursing Management During Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potentia Reference: p. 497 3. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A. +2 station. B. 0 station. C. -2 station. D. crowning. Answer: C Rationale: The ischial spines serve as landmarks and are designaatebdirb.acsomz/etersot status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to thabei rba.pc opme/at ersat nce of the fetal head at the vaginal opening. Question format: Multiple Choice Chapter 14: Nursing Management During Labor and Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Reference: p. 468 4. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns: A. yellow. B. olive green. C. pink. D. blue. Answer: D