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The nurse is caring for a patient during induction of labor. The oxytocin is currently infusing at 6 mU/min. The fetal heart tracing displays a 130 baseline, moderate variability, and no accelerations or decelerations. Uterine contractions have been every 2 minutes for the last 30 minutes. What is the nurse’s next best action?
- A. Reduce the oxytocin infusion to 3 mU/min
- B. Delay the next scheduled oxytocin increase
- C. Maintain infusion at 6 mU/min
- D. Discontinue the oxytocin infusion
Correct Answer: C
Rationale: The fetal heart rate (FHR) is stable, with moderate variability and no decelerations, indicating that the fetus is not in distress. The contractions are occurring at appropriate intervals, so the nurse should maintain the current oxytocin infusion to continue labor progression.
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What effect will the presence of support people in labor most likely have?
- A. improve the experience of the birthing person
- B. improve the outcomes of the birthing person
- C. improve the outcomes and experience of the birthing person
- D. cause birth trauma and/or postpartum depression
Correct Answer: C
Rationale: The presence of support people during labor, such as a partner, family member, doula, or midwife, can have a positive impact on both the outcomes and experience of the birthing person. Studies have shown that having continuous support during labor can lead to shorter labor times, reduced need for medical interventions like cesarean sections or epidurals, increased satisfaction with the birth experience, and decreased likelihood of experiencing postpartum depression. Emotional support, physical comfort, and advocacy provided by support people can help the birthing person feel more empowered, confident, and less stressed during labor, ultimately leading to better outcomes and a more positive birth experience.
How can a nurse support the patient during the fourth stage of labor?
- A. Support pushing efforts with feedback on how much progress is being made
- B. Ensure epidural anesthesia is adequate for pain control, reposition frequently, provide dietary intake per provider's order.
- C. Assess for any bleeding or amniotic fluid presence in the vaginal discharge
- D. Provide rest, space, and time for bonding between assessments, support for feeding
preferences, diligent monitoring for complications, pain management.
Correct Answer: D
Rationale: During the fourth stage of labor, it is important for the nurse to provide a supportive and nurturing environment for the mother and baby. This stage occurs immediately after the baby is born and lasts for about 2 hours. The mother may be exhausted from the physical effort of labor and delivery, so providing rest, space, and time for bonding between assessments is crucial. The nurse should also support the mother's feeding preferences, whether it is breastfeeding or formula feeding. Diligent monitoring for complications, such as postpartum hemorrhage or infection, is essential during this stage. Additionally, providing adequate pain management for any discomfort the mother may be experiencing is important.
A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.)
- A. In true labor, the cervix begins to dilate
- B. In true labor, the contractions are felt in the abdomen and groin.
- C. In true labor, contractions often resemble menstrual cramps during early labor.
- D. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.
Correct Answer: A
Rationale: A. In true labor, the cervix begins to dilate: One of the key signs of true labor is that the cervix starts to dilate (open up) as the body prepares for childbirth. If a woman is experiencing real labor, her cervix will gradually start to open up to allow the baby to pass through the birth canal.
The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%/+1. What instruction will the nurse implement with the patient?
- A. "You will need to remain in bed attached to the electronic fetal monitor.”
- B. "Breathe with me slowly, in through your nose and out through your mouth.”
- C. "I will begin the administration of 1000 mL of IV fluid so you can have an epidural.”
- D. "Your partner will need to change into scrub attire to attend the imminent birth.”
Correct Answer: A
Rationale: The notation "3/50%/+" in the patient's record indicates that the patient is dilated 3 cm, the effacement is 50%, and the presenting part of the fetus is at +1 station. This information signifies that the patient is in active labor. The nurse should implement the instruction of having the patient remain in bed attached to the electronic fetal monitor to closely monitor the progression of labor and the well-being of the fetus. This will allow for continuous assessment and prompt interventions as needed.
During the second stage, what do the birthing person's vital signs most likely show?
- A. increased heart rate during contractions, baseline heart rate between contractions
- B. increased heart rate during contractions, decreased heart rate between contractions
- C. decreased heart rate during contractions, increased heart rate between contractions
- D. decreased heart rate during contractions, baseline heart rate between contractions
Correct Answer: A
Rationale: During the second stage of labor (pushing stage), the birthing person's vital signs most likely show an increased heart rate during contractions and a baseline heart rate between contractions. This increase in heart rate is a normal physiological response to the exertion and pressure of pushing during contractions. Between contractions, the heart rate should return to a more stable baseline. It is important to monitor these vital signs to ensure the well-being of both the birthing person and the baby during childbirth.