Nokea
A 35-year-old gravida 1, para 0 is admitted to the labor and delivery unit. She reports intense rectal pressure. Which stage of labor is probable?
- A. First stage, latent
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: B
Rationale: The correct answer is B: Second stage. In the second stage of labor, the cervix is fully dilated, and the woman experiences the urge to push. The intense rectal pressure reported by the patient indicates the baby's descent into the birth canal, a characteristic of the second stage. In contrast, in the first stage (choices A and C), the cervix is still dilating, and in the fourth stage (choice D), immediate postpartum period, the focus is on maternal stabilization.
You may also like to solve these questions
Arrange the seven cardinal movements of labor, in order.
- A. Descent
- B. Expulsion
- C. Extension
- D. External rotation
Correct Answer: A
Rationale: The correct order of cardinal movements of labor is:
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution
7. External rotation
Engagement occurs first as the fetal presenting part enters the maternal pelvis. Descent is the second cardinal movement, where the fetus moves down the birth canal. Flexion follows, allowing the smallest diameter of the fetal head to present. Internal rotation positions the fetus for delivery. Extension occurs next, facilitating the passage of the head through the birth canal. Restitution aligns the fetal head with the shoulders. External rotation allows the shoulders to rotate for delivery. Therefore, Descent is the correct first cardinal movement in the sequence. Other choices like Expulsion, Extension, and External rotation occur later in the process and are not in the correct order.
What changes in hormones initiate labor?
- A. decreased progesterone, decreased estrogen, absence of oxytocin
- B. increased progesterone, decreased estrogen, absence of oxytocin
- C. increased progesterone, decreased estrogen, presence of oxytocin
- D. decreased progesterone, increased estrogen, effects of oxytocin
Correct Answer: D
Rationale: The correct answer is D because decreased progesterone, increased estrogen, and the effects of oxytocin are the hormonal changes that initiate labor. Progesterone inhibits contractions, so its decrease allows labor to begin. Estrogen promotes uterine sensitivity to oxytocin, which stimulates contractions. Oxytocin is released in response to labor contractions and helps to strengthen contractions.
A: Incorrect because decreased progesterone is needed for labor to start, estrogen needs to increase, and oxytocin is present during labor.
B: Incorrect because increased progesterone inhibits labor, estrogen should increase, and oxytocin is present during labor.
C: Incorrect because progesterone should decrease, estrogen should increase, and oxytocin is present during labor.
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.
The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
- A. Offer the patient a warm blanket.
- B. Place an ice pack on the perineum.
- C. Massage the uterus if it is boggy.
- D. Delay breastfeeding until the patient is reste
Correct Answer: A
Rationale: The correct answer is A: Offer the patient a warm blanket. In the fourth stage of labor, the mother experiences postpartum hemorrhage risk due to uterine atony. Keeping the patient warm helps prevent hypothermia, which can lead to increased bleeding. Ice packs (B) are not indicated as they can cause vasoconstriction and inhibit proper blood flow. Massaging the uterus (C) is appropriate in the third stage of labor to prevent hemorrhage but not in the fourth stage. Delaying breastfeeding (D) is incorrect as early breastfeeding promotes uterine contractions, reducing the risk of postpartum hemorrhage.
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: The correct answer is C because during the active phase of labor, the cervix dilates from 4 to 7 centimeters, and the patient typically experiences the urge to push as the baby descends further down the birth canal. This indicates progress in labor and readiness for the second stage. Choices A, B, and D are incorrect as they do not specifically align with the characteristics of the active phase of labor. Choice A is not necessarily indicative of the active phase, choice B may happen at any stage of labor, and choice D is more characteristic of transition phase rather than the active phase.