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In a research study performed by Schneuder, L., Crenshaw, J., and Gilder, R. (2017), which action by the nurse will be implemented following a cesarean delivery?
- A. Allow the birth partner to hand the neonate to the mother.
- B. Assist the mother and partner to cut the umbilical cord.
- C. Move the neonate into the visual field of the mother.
- D. Encourage skin-to-skin contact between the mother and neonate.
Correct Answer: D
Rationale: The correct answer is D: Encourage skin-to-skin contact between the mother and neonate. This action is crucial following a cesarean delivery to promote bonding, regulate the baby's temperature, and facilitate breastfeeding. Skin-to-skin contact also helps stabilize the baby's heart rate, breathing, and blood sugar levels.
A: Allowing the birth partner to hand the neonate to the mother may be a good practice but is not as essential as skin-to-skin contact for immediate benefits.
B: Assisting the mother and partner to cut the umbilical cord is not typically the nurse's responsibility immediately after a cesarean delivery and does not provide the same benefits as skin-to-skin contact.
C: Moving the neonate into the visual field of the mother is important for bonding but does not offer the same physiological benefits as direct skin-to-skin contact.
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How much blood loss must occur to define the loss as a postpartum hemorrhage?
- A. 250 mL
- B. 500 mL
- C. 750 mL
- D. 1,000 mL
Correct Answer: B
Rationale: The correct answer is B (500 mL) for defining postpartum hemorrhage. This amount is used as the threshold because it represents a significant loss that may lead to maternal complications. Excessive bleeding after childbirth can quickly become life-threatening, so it is crucial to define postpartum hemorrhage accurately. Choices A (250 mL), C (750 mL), and D (1,000 mL) are incorrect as they do not align with the standard definition of postpartum hemorrhage, which is typically considered when blood loss exceeds 500 mL.
The patient presenting at 38 weeks' gestation, gravida 1, para 0, vaginal exam 4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern?
- A. Continue oxytocin (Pitocin) infusion.
- B. Contact the anesthesia department for epidural administration.
- C. Change maternal position.
- D. Administer Narcan to patient and prepare for immediate vaginal delivery.
Correct Answer: C
Rationale: The correct answer is C: Change maternal position. At 38 weeks' gestation with 4 cm dilation and 100% effacement, the fetal heart rate pattern suggests possible umbilical cord compression due to the +1 station vertex position. Changing maternal position can relieve this compression, improving fetal heart rate. Continuing oxytocin infusion (A) can worsen the situation by increasing contractions. Contacting anesthesia for epidural (B) is not indicated as it doesn't address the immediate concern. Administering Narcan and preparing for immediate delivery (D) is unnecessary and not supported by the given scenario.
What is a potential sign of intrauterine fetal demise?
- A. increased fetal heart rate
- B. vaginal bleeding
- C. decreased or absent fetal movement
- D. macrosomia
Correct Answer: C
Rationale: The correct answer is C: decreased or absent fetal movement. This is a potential sign of intrauterine fetal demise because it indicates a lack of fetal activity, which could suggest fetal distress or death. Reduced or absent fetal movement may be an early warning sign that the fetus is not receiving enough oxygen or nutrients. It is important to monitor fetal movement regularly to ensure the well-being of the fetus.
Other choices are incorrect because:
A: increased fetal heart rate is more commonly associated with fetal distress, not demise.
B: vaginal bleeding can be a sign of various conditions such as placental abruption or placenta previa, but it is not specific to fetal demise.
D: macrosomia refers to a large baby, which is not indicative of fetal demise.
In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding?
- A. The fetus is at 30 weeks of gestation.
- B. The mother has a history of fast labors.
- C. The mother has been given an epidural block.
- D. The mother has mild preeclampsia but is not in labor.
Correct Answer: A
Rationale: The correct answer is A because at 30 weeks of gestation, a fetal heart rate of 160 to 170 bpm is considered normal due to the fetus's stage of development. Fetal heart rates gradually decrease as gestation progresses. Choices B, C, and D are incorrect because they do not directly impact the fetal heart rate based on gestational age. Choice B, fast labors, does not affect the baseline fetal heart rate. Choice C, epidural block, may cause maternal hypotension but typically doesn't affect the fetal heart rate. Choice D, mild preeclampsia, may lead to fetal distress but does not directly influence the baseline fetal heart rate.
The nurse is aware that there are multiple classifications for cesarean deliveries. Which situations does the nurse classify as an unscheduled cesarean birth? Select all that apply.
- A. Patient had a previous cesarean delivery.
- B. There is evidence of a prolapsed cord with membrane rupture.
- C. The cervix fails to fully dilate after prolonged labor.
- D. Patient has a preexisting cardiac health condition.
Correct Answer: C
Rationale: The correct answer is C because an unscheduled cesarean birth occurs when the cervix fails to fully dilate after prolonged labor, leading to the need for an emergency cesarean section. This situation poses risks to both the mother and the baby, necessitating immediate intervention.
Choice A is incorrect because a previous cesarean delivery does not necessarily mean the current cesarean birth is unscheduled. Choice B is incorrect as evidence of a prolapsed cord with membrane rupture would typically lead to an emergency cesarean delivery but is not the only scenario for unscheduled cesarean birth. Choice D is also incorrect as a preexisting cardiac health condition does not automatically indicate the need for an unscheduled cesarean birth.