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A 28-year-old gravida 1, para 0 patient who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet;
- A. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. Which questions should the nurse pose to the patient during this telephone triage? (Select all that apply.)
- B. Does she think that her membranes have ruptured?
- C. Is there any evidence of bloody show?
- D. Instruct the patient to keep monitoring her contraction pattern and call you back if they become more regular.
Correct Answer: A
Rationale: The correct answer is A because the patient's irregular contraction pattern and varying duration indicate early labor. By asking the patient about the contraction pattern, the nurse can assess the progression of labor and provide appropriate guidance. Choice B is incorrect because if the patient's membranes have ruptured, she would most likely feel a gush of fluid rather than just feeling wet. Choice C is incorrect as bloody show is not typically a reliable indicator of early labor. Choice D is incorrect as it does not address the need to assess the contraction pattern for progression of labor.
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The nurse is assessing a patient in the active phase of labor. What should the nurse expect during this phase?
- A. The patient is sociable and excite
- B. The patient is requesting pain medication.
- C. The patient begins to experience the urge to push.
- D. The patient experiences loss of control and irritability.
Correct Answer: C
Rationale: During the active phase of labor, contractions become stronger and more frequent, leading to cervical dilation. This is when the patient typically experiences the urge to push as the cervix reaches around 7-10 cm dilation. This signifies progress towards the second stage of labor. Choices A, B, and D are incorrect as they do not specifically align with the characteristics of the active phase of labor. A patient may exhibit a range of emotions and behaviors during labor, but the key indicator of the active phase is the urge to push due to cervical dilation.
Why is precipitous labor most often seen in multiparous women?
- A. The cervix weakens after each delivery.
- B. The cervix can dilate and efface simultaneously.
- C. The multigravida uterus is better able to coordinate muscle movements.
- D. It is more difficult for multiparous women to know when labor begins.
Correct Answer: C
Rationale: Step 1: In multiparous women, the uterus has gone through labor before, making muscle coordination more efficient.
Step 2: Efficient muscle coordination helps in effective contractions, leading to faster labor progress.
Step 3: Multiparous women have experienced labor before, allowing the uterus to contract more effectively.
Step 4: This efficiency in muscle coordination is why precipitous labor is more often seen in multiparous women.
Summary:
A: The weakening of the cervix after each delivery is not a direct cause of precipitous labor.
B: The ability of the cervix to dilate and efface simultaneously does not explain why precipitous labor is more common in multiparous women.
D: The difficulty in knowing when labor begins is not a reason for the occurrence of precipitous labor in multiparous women.
A gravida 3, para 2 is attempting a vaginal birth without the use of pain medicine or anesthesia. Following spontaneous rupture of membranes, the patient’s cervical exam was 5 cm dilated, 60% effaced, -2 station. Which therapeutic intervention is appropriate for this patient?
- A. Ambulation with assistance
- B. Squatting with support from partner
- C. Sitting on birthing ball
- D. Resting on hands and knees
Correct Answer: C
Rationale: The correct answer is C: Sitting on birthing ball. This position helps to open up the pelvis, allowing for optimal fetal positioning and descent. It also helps relieve pressure on the cervix, promoting dilation. Ambulation (A) may slow down labor progress, squatting (B) can increase pressure on the cervix and hinder descent, and resting on hands and knees (D) may not be as conducive to gravity-assisted descent.
Pregnant patients can usually tolerate the normal blood loss associated with childbirth because of which physiologic adaptation to pregnancy?
- A. A higher hematocrit
- B. Increased leukocytes
- C. Increased blood volume
- D. A lower fibrinogen level
Correct Answer: C
Rationale: The correct answer is C: Increased blood volume. During pregnancy, a woman's blood volume increases by about 30-50% to support the growing fetus and prepare for potential blood loss during childbirth. This increased blood volume helps pregnant patients tolerate the normal blood loss associated with childbirth without experiencing severe complications like hypovolemic shock.
Rationale:
A: A higher hematocrit would not directly contribute to increased blood volume and would not help in tolerating blood loss during childbirth.
B: Increased leukocytes are part of the immune response and are not directly related to blood volume or tolerance to blood loss.
D: A lower fibrinogen level would not directly contribute to increased blood volume and would not help in tolerating blood loss during childbirth.
Summary:
Choice C is correct because increased blood volume is a crucial physiologic adaptation during pregnancy that enables pregnant patients to tolerate the normal blood loss associated with childbirth. Choices A, B, and D are incorrect as they are not directly related to this
The labor and delivery nurse is caring for a 27-year-old primigravida with the following vaginal exam: 2 to 3 cm dilated/70% effaced/-2 station. For the last 2 hours the FHR tracing has displayed a Category I tracing and uterine contractions that are every 2 minutes. The contractions are strong to palpation and the patient is now 3/70%/-2. Which is the nurse’s next best action?
- A. Encourage the patient to ambulate
- B. Request orders to initiate oxytocin
- C. Assist the patient to a warm bath
- D. Document the findings
Correct Answer: D
Rationale: The correct answer is D, documenting the findings. In this scenario, the patient is in active labor with regular strong contractions, cervical change, and a reassuring fetal heart rate tracing. The priority is to document these important clinical findings accurately for proper assessment and monitoring of progress. Encouraging ambulation (A) may not be safe due to the frequency and strength of contractions. Initiating oxytocin (B) is unnecessary as labor is progressing well on its own. Assisting the patient to a warm bath (C) may provide comfort but is not the most critical action at this time.