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A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
- A. A nitrazine test is the most conclusive test.
- B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.
- C. Ferning is more conclusive than nitrazine paper testing.
- D. Note if there is fluid leaking from the perineal area.
Correct Answer: A
Rationale: The correct answer is A. The nurse should perform a nitrazine test to determine if the fluid leaking is amniotic fluid. Here's the rationale:
1. Nitrazine test is specifically designed to differentiate amniotic fluid from urine.
2. Amniotic fluid is alkaline, causing the nitrazine paper to turn blue when it comes into contact with it.
3. Urine, on the other hand, does not change the color of the nitrazine paper.
4. This test is quick, easy to perform, and provides a conclusive result in differentiating amniotic fluid from other fluids.
In summary:
- Choice B incorrectly describes the color change mechanism of nitrazine paper.
- Choice C refers to ferning, which is not as conclusive as the nitrazine test.
- Choice D does not provide a definitive method for determining if the leaking fluid is amniotic fluid.
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Which assessment finding would cause a concern for a patient who had delivered vaginally?
- A. Estimated blood loss (EBL) of 500 mL during the birth process
- B. White blood cell count of 28,000 mm3 postbirth
- C. Patient complains of fingers tingling
- D. Patient complains of thirst
Correct Answer: B
Rationale: The correct answer is B - White blood cell count of 28,000 mm3 postbirth. This finding indicates a possible infection or inflammation, which can be concerning after vaginal delivery. A high white blood cell count may suggest an ongoing infection that needs immediate attention.
A: Estimated blood loss of 500 mL is within normal range for vaginal delivery and is not a cause for concern.
C: Fingers tingling may be due to various reasons unrelated to the delivery process and is not a typical concern post vaginal delivery.
D: Thirst is a common symptom post-delivery and is not indicative of a serious complication.
Which of the following is a function of a doula during labor?
- A. Administration of oral pain medications
- B. Assess fetal heart rate
- C. Perform vaginal examination with the mother’s permission
- D. Provide nonpharmacological pain relief
Correct Answer: D
Rationale: The correct answer is D: Provide nonpharmacological pain relief. A doula's role is to offer emotional support, comfort measures, and advocacy during labor. Providing nonpharmacological pain relief techniques such as massage, breathing exercises, and positioning is within the scope of a doula's practice. This helps the mother cope with labor discomfort without the use of medication.
Choice A is incorrect because doulas do not administer medications. Choice B is incorrect as assessing fetal heart rate is typically done by healthcare providers. Choice C is incorrect as performing vaginal examinations is not a part of a doula's role.
What makes up the powers of labor and birth?
- A. contractions and pushing efforts
- B. pelvis and pelvic floor tissues
- C. fetal position, attitude, lie, and presentation
- D. oxytocin
Correct Answer: A
Rationale: The correct answer is A: contractions and pushing efforts. During labor and birth, contractions help to dilate the cervix and push the baby down the birth canal. Pushing efforts from the mother help to expel the baby out. Pelvis and pelvic floor tissues (choice B) provide the passage for the baby but do not actively contribute to the powers of labor. Fetal position, attitude, lie, and presentation (choice C) refer to the baby's position and orientation in the womb, which can affect the progress of labor but do not constitute the powers of labor. Oxytocin (choice D) is a hormone that stimulates contractions but is not the sole component of the powers of labor and birth.
A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?
- A. Notify the operating team of emergent cesarean delivery
- B. Assist the patient to left lateral position
- C. Apply O2 at 10-12 L/min per nonrebreather
- D. Administer an IV fluid bolus
Correct Answer: A
Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. Given the scenario of a gravida 2, para 1 in active labor with bloody fluid and fetal heart decelerations to the 50s following amniotomy, these signs indicate fetal distress. In this critical situation, immediate intervention with emergent cesarean delivery is necessary to prevent adverse outcomes for the baby. This step takes priority over other actions, as it ensures timely delivery and assessment of the fetus's well-being. Choices B, C, and D are not appropriate in this emergent situation as they do not directly address the fetal distress and the need for expedited delivery.
Which assessment finding would cause a concern for a patient who had delivered vaginally?
- A. Estimated blood loss (EBL) of 500 mL during the birth process
- B. White blood cell count of 28,000 mm3 postbirth
- C. Patient complains of fingers tingling
- D. Patient complains of thirst
Correct Answer: B
Rationale: The correct answer is B because a white blood cell count of 28,000 mm3 postbirth indicates a possible infection, such as endometritis, which is a common postpartum complication. Elevated WBC count is a sign of an inflammatory process or infection, requiring further investigation and treatment.
A: EBL of 500 mL is within the normal range for a vaginal delivery and may not necessarily indicate a concern.
C: Patient complaints of fingers tingling may suggest temporary nerve compression or positional discomfort, not a significant concern post vaginal delivery.
D: Patient complaining of thirst is a common symptom and not necessarily indicative of a complication post vaginal delivery.