Nokea
A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?
- A. Active
- B. Transition
- C. Latent
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase.
Summary:
A: Active phase occurs when the cervix is dilated from 4 to 7 cm.
C: Latent phase occurs when the cervix is dilated from 0 to 3 cm.
D: Descent phase is not a recognized phase of labor.
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A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)
- A. Breast tenderness
- B. Urinary frequency
- C. Epistaxis
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. At 6 weeks of gestation, common discomforts include breast tenderness due to hormonal changes, urinary frequency from increased blood flow to kidneys, and epistaxis (nosebleeds) due to increased blood volume and vessel fragility. Therefore, all options are relevant and should be included in the education. Other choices are incorrect because they do not encompass all the common discomforts experienced during early pregnancy.
A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?
- A. Assist the client into the left-lateral position
- B. Apply a fetal scalp electrode
- C. Insert an IV catheter
- D. Perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress.
Summary of other choices:
B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring.
C: Inserting an IV catheter is important but not the priority when late decelerations are observed.
D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.
A healthcare professional is assessing four newborns. Which of the following findings should the professional report to the provider?
- A. A newborn who is 26 hours old and has erythema toxicum on their face
- B. A newborn who is 32 hours old and has not passed meconium stool
- C. A newborn who is 12 hours old and has pink-tinged urine
- D. A newborn who is 18 hours old and has an axillary temperature of 37.7° C (99.9° F)
Correct Answer: D
Rationale: The correct answer is D because an axillary temperature of 37.7°C (99.9°F) in a newborn is above the normal range and could indicate a fever, which is a significant concern in newborns due to their immature immune systems. Fever in newborns can be a sign of serious infections that require immediate medical attention.
A: Erythema toxicum is a common rash in newborns and typically resolves on its own without medical intervention.
B: Failure to pass meconium stool by 48 hours may be a concern but not as urgent as a fever.
C: Pink-tinged urine in the first few days of life is likely due to uric acid crystals and is considered normal in newborns.
During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?
- A. Maternal fever
- B. Fetal heart failure
- C. Maternal hypoglycemia
- D. Fetal head compression
Correct Answer: A
Rationale: The correct answer is A: Maternal fever. Maternal fever can lead to tachycardia in the fetus due to the transfer of maternal antibodies, cytokines, and other inflammatory mediators across the placenta, affecting fetal heart rate. Maternal fever can indicate infection, which can cause fetal distress. The other choices are incorrect because:
B: Fetal heart failure typically presents with bradycardia, not tachycardia.
C: Maternal hypoglycemia can affect the fetus but is more likely to cause fetal bradycardia than tachycardia.
D: Fetal head compression can result in decelerations but not necessarily tachycardia.
During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?
- A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
- B. A fourth-degree episiotomy extends into the rectal area and is not recommended
- C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
- D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries
Correct Answer: C
Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure.
A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client.
B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter.
D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.