Question 5371)
Which nursing action has the highest priority for a client in the second stage of
labor?
A. Help the mother push effectively
B. Prepare the mother to breastfeed on the delivery table
C. Check the fetal position
D. Administer medication for pain
Answer: A
Explanation: The second stage of labor is the pushing stage. The nurse should help the mother push effectively.
Answer 2 is not correct. The mother cannot breastfeed the infant until it is born. Breastfeeding on the delivery
table might be an appropriate action in the third stage of labor. Answer 3 is not correct. Checking the fetal position
is not the highest priority action during second stage labor. Answer 4 is not correct. Pain medication should not be
administered in the second stage because it will cause a sleepy baby.
Question 5372)
A woman, gravida 5, para 4, is unable to get to the hospital because labor has
progressed very rapidly. A nurse, who lives upstairs, comes down to assist her with the emergency
home delivery. The nurse examines the woman and assesses that the perineum is bulging. What is
the priority nursing measure at this time?
A. Encourage the woman to push during the contraction
B. Place a clean sheet under the perineal area
C. Accurately time the contractions
D. Contact the physician by phone for instructions
Answer: B
Explanation: The woman is a gravida 5, para 4, and the perineum is bulging. Delivery is imminent. Contamination
will be minimized by catching the infant on a clean surface. Answer 1 is not correct. The woman will not need to
be encouraged to push; she will be doing it on her own. Secondly, it will be more appropriate to have her pant so
that the delivery can be controlled. Answer 3 is not correct. Delivery is imminent. There is no time or need to time
the contractions. Answer 4 is not correct. Delivery is imminent. There is no time to contact the physician for
instructions. The nurse should be able to handle this emergency delivery.
Question 5373)
During an emergency home delivery, the head is beginning to crown. What is the
most appropriate action for the nurse to take at this time?
A. Instruct the mother to push down vigorously.
B. Press down on the fundus to expel the baby
C. Apply gentle perineal pressure to prevent rapid expulsion of the head.
D. Direct the mother to take prolonged deep breaths to improve fetal oxygenation.
Answer: C
Explanation: Applying gentle counter pressure to the perineum prevents too rapid expulsion of the head, which can
lead to increased intracranial pressure in the infant and laceration in the mother. Answer 1 is not correct. The
mother will be encouraged to pant so that the delivery can be controlled. Answer 2 is not correct. The nurse does
not press down on the fundus to expel the baby. Answer 4 is not correct. There is no need to tell the mother to
take prolonged deep breaths. Applying gentle perineal pressure is by far the most appropriate action for the nurse
at this time.
Question 5374)
What is the most common complication associated with too rapid delivery in
precipitate labor?
A. Pitting edema of the baby’s scalp
B. Dural or subdural tears in fetal brain tissue
C. Premature separation of the placenta
D. Prolonged retention of the placenta
Answer: B
Explanation: The sudden change of pressure tends to tear away dural linings. The mother can also get perineal
tears. Answer 1 is not correct. Edema of the scalp is not a complication with precipitate labor. Sometimes
prolonged labor can cause caput succedaneum, where the baby has bleeding under the scalp. Answers 3 and 4 are
not correct. Rapid delivery is not particularly associated with placental problems.
Question 5375)
The nurse has just completed emergency delivery of a term infant. What is the
priority nursing concern at this time?
A. Controlling hemorrhage in the mother
B. Removing the afterbirth
C. Keeping the infant warm
D. Cutting the umbilical cord
Answer: C
Explanation: Newborns have immature temperature regulating mechanisms. The nurse should dry the infant and
place the infant in a blanket or towel on the mother’s abdomen. Answer 1 is not correct. The first concern is
clearing the infant’s airway and keeping the infant warm. The mother is not likely to hemorrhage at this time.
Maternal hemorrhage would be more likely after delivery of the placenta. Answer 2 is not correct. The afterbirth
or placenta should separate and deliver itself within 5 to 15 minutes after the baby is born. The nurse should care
for the baby until this happens. Answer 4 is not correct. There is no hurry to cut the cord. The cord should never
be cut with anything that is not sterile because the baby could develop a fatal infection.
Question 5376)
What should the nurse do to stimulate the separation of the placenta after home
delivery of a baby?
A. Ask the mother to push down vigorously
B. Push the fundus down vigorously
C. Encourage the baby to breastfeed
D. Place gentle tension on the umbilical cord
Answer: C
Explanation: Breastfeeding stimulates uterine contractions, which will help the placenta to separate. Answer 1 is
not correct. Having the mother push down vigorously will not stimulate the placenta to separate. Answer 2 is not
correct. The nurse should not push down on the fundus. This is not necessary for the placenta to separate. Answer
4 is not correct. The nurse should never pull on the cord. This could cause inversion of the uterus.
Question 5377)
A woman delivered a baby in the car on the way to the hospital. In the emergency
room, the physician examined the mother. What is the priority action for the nurse at this time?
A. Gently tug on the cord and massage the uterus to see if the placenta is ready to be delivered
B. Clamp and cut the cord with sterile scissors
C. Note and record the Apgar score
D. Clear the mucus from the baby’s mouth and nose
Answer: D
Explanation: A clear airway for the infant is first priority. Answer 1 is not correct. Tugging on the cord before the
placenta is expelled could cause inversion of the uterus. Answer 2 is not correct. The cord does not need to be cut
immediately. Clearing the infant’s airway is a much higher priority. Answer 3 is not correct. The nurse may assess
the infant and get an Apgar score. However, the airway is a much higher priority than the Apgar.
Question 5378)
A woman who is giving birth at home wonders if her baby will need drops in the
eyes because she knows that neither she nor her husband has gonorrhea. The best answer for the
nurse to give should include which of the following?
A. It is desirable for the baby to receive the eye drops, but it is not essential.
B. If you do not want your baby to have the eye drops, you must sign a waiver stating that you refuse them.
C. The baby needs the drops but does not have to receive them for up to two hours after birth.
D. The drops are needed to prevent the eye condition known as retrolental fibroplasia.
Answer: C
Explanation: Antibiotic eye drops have to be instilled into the neonate’s conjunctival sacs to prevent infection, not
just from gonorrhea and chlamydia but also from pathogens in the birth canal such as pneumococcus and
Streptococcus. It is safe to wait up to two hours to instill the drops. This allows time for maternal-child eye contact
and interaction, which facilitates attachment. Answers 1 and 2 are not correct. There is a legal requirement to
give the baby eye prophylaxis. Answer 4 is not correct. Retrolental fibroplasia results from too much oxygen
concentration in immature retinal vessels during oxygen therapy for the compromised neonate.
Question 5379)
The nurse is caring for a laboring woman who has a history of rheumatic heart
disease. How should the nurse position her during labor?
A. Supine
B. Semi-recumbent
C. Side-lying
D. Sitting
Answer: B
Explanation: Semi-recumbent or semi-Fowler’s position would be the most appropriate position to reduce the
cardiac work load and ease breathing. The laboring woman who has a history of rheumatic heart disease is at risk
for congestive heart failure. The supine and side-lying positions would increase the cardiac work load. Sitting
upright is not the best choice.
Question 5380)
The nurse is caring for a laboring woman who has a history of rheumatic heart
disease. Which instruction should the nurse give to her during the second stage of labor?
A. Avoid prolonged bearing down.
B. Breathe shallowly and rapidly
C. Sit on the side of the bed
D. Sleep between contractions.
Answer: A
Explanation: The woman with cardiac disease should not bear down excessively. She will likely be given an epidural
anesthesia, and outlet forceps may be indicated to shorten the second stage of labor. Answer 2 is not correct.
Breathing shallowly and rapidly will cause respiratory alkalosis. Answer 3 is not correct. Sitting on the side of the
bed is not an appropriate action during second stage labor. Second stage labor is the expulsion stage. Answer 4 is
not correct. Sometimes mothers do doze between contractions in second stage. However, answer 1 is the priority
instruction that the nurse should give this mother.
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