Exam (elaborations)
Chapter 16 Labour and Birth Processes
- Course
- Maternal child nursing
- Institution
- Rutgers School Of Nursing
Chapter 16 Labour and Birth Processes
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Chapter 16: Labour and Birth ProcessesMULTIPLE CHOICE
1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. The nurse’s
answer is based on the knowledge that the anterior fontanel closes how many months after
birth?
a. 2 months
b. 8 months
c. 12 months
d. 18 months
ANS: D
The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.
DIF: Cognitive Level: Knowledge REF: p. 402 OBJ: Nursing Process: Planning
2. What is the term for the relationship of the fetal body parts to one another?
a. Lie
b. Presentation
c. Attitude
d. Position
ANS: C
Attitude is the relation of the fetal body parts to one another. Lie is the relation of the long axis
(spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the
fetus that enters the pelvic inlet first and leads through the birth canal during labour at term.
Position is the relation of the presenting part to the four quadrants of the mother’s pelvis.
DIF: Cognitive Level: Knowledge REF: p. 402
OBJ: Nursing Process: Assessment
3. The nurse has received a report about a woman in labour. The woman’s last vaginal
examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this
assessment?
, a.
30%, and the presenting part is 2 cm
above the ischial spines.
b. The cervix is 3 cm dilated, it is effaced
30%, and the presenting part is 2 cm
above the ischial spines.
c. The cervix is effaced 3 cm, it is dilated
30%, and the presenting part is 2 cm
below the ischial spines.
d. The cervix is dilated 3 cm, it is effaced
30%, and the presenting part is 2 cm
below the ischial spines.
ANS: B The
cervix is effaced 3 cm, it is dilated
The correct description of the vaginal examination for this woman in labour is the cervix is 3 cm
dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile
vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical
dilation, and the relationship of the presenting part to the ischial spines (either above or
below).
DIF: Cognitive Level: Comprehension REF: p. 405 | p. 408
OBJ: Nursing Process: Assessment | Nursing Process: Planning
4. Which position would be least effective when gravity is needed to assist in fetal descent?
a. Lithotomy
b. Kneeling
c. Sitting
d. Walking
ANS: A
Lithotomy position requires a woman to be in a reclined position with her legs in stirrups.
Gravity has little effect in this position. Kneeling, sitting, and walking help align the fetus with
the pelvic outlet and allow gravity to assist in fetal descent.
DIF: Cognitive Level: Analysis REF: p. 409
OBJ: Nursing Process: Planning | Nursing Process: Implementation
5. Which position would the nurse suggest for second-stage labour if the pelvic outlet needs to be
increased?
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