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The nurse is educating a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions relieved by rest.
- B. Contractions felt only in the abdomen.
- C. Contractions that increase in intensity and cause cervical changes.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by contractions that progressively increase in intensity and result in cervical dilation and effacement.
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A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
The nurse is performing Leopold's maneuvers on a client in labor. What is the primary purpose of this assessment?
- A. Evaluate fetal heart rate.
- B. Determine fetal position and presentation.
- C. Check for uterine contractions.
- D. Assess amniotic fluid volume.
Correct Answer: B
Rationale: Leopold's maneuvers help identify fetal position, presentation, and engagement for labor management.
A client in labor is receiving an epidural for pain relief. What is the nurse's priority assessment immediately after the procedure?
- A. Monitor maternal blood pressure.
- B. Assess fetal heart rate.
- C. Check for bladder distention.
- D. Evaluate the client's pain level.
Correct Answer: A
Rationale: Monitoring maternal blood pressure is essential to detect and manage hypotension, a common side effect of epidurals.
What is the recommended position for a laboring mother with variable decelerations?
- A. Position the mother in a supine position
- B. Encourage the mother to change positions frequently
- C. Advise using a peanut ball to widen the pelvis
- D. Position the mother in a side-lying position
Correct Answer: D
Rationale: Side-lying reduces pressure on the umbilical cord, improving fetal oxygenation.
A mother is learning how to breastfeed her newborn. tions, moderate variability The lactation nurse is assisting her with this process.
- A. Baseline FHR 140, occasional variable decelera- Which technique is correct? tions, moderate variability
- B. Have the mother stroke the infant's mouth with
- C. Baseline FHR 105, no accelerations, recurrent her nipple so the infant will turn toward the variable decelerations, minimal variability mother's breast for feeding.
- D. Baseline FHR 165, no decelerations, marked
Correct Answer: B
Rationale: Having the mother stroke the infant's mouth with her nipple so the infant will turn toward the mother's breast for feeding is the correct technique when assisting a mother in learning how to breastfeed her newborn. This technique helps stimulate the baby's rooting reflex, which is a natural reflex babies have to turn their head and open their mouth when their cheek is stroked.