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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.
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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.
A woman’s pelvis is described as long and narrow with an anteroposterior diameter greater than the transverse diameter. This is known as which type of pelvis?
- A. Platypelloid
- B. Android
- C. Anthropoid
- D. Gynecoid
Correct Answer: C
Rationale: The correct answer is C: Anthropoid. An anthropoid pelvis is characterized by a long and narrow shape with an anteroposterior diameter greater than the transverse diameter. This type of pelvis resembles the pelvic structure of anthropoid (higher primates) mammals. The other choices are incorrect because:
A: Platypelloid pelvis is flat and broad, not long and narrow.
B: Android pelvis has a heart-shaped inlet with an android appearance, not a long and narrow shape.
D: Gynecoid pelvis is rounded and wider with a transverse diameter greater than the anteroposterior diameter, opposite of the described characteristics.
Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?
- A. Station
- B. Flexion
- C. Descent
- D. Engagement
Correct Answer: B
Rationale: The correct answer is B: Flexion. Flexion of the fetal head is crucial for the smallest anterior-posterior diameter to enter the pelvis first. This position optimizes the fit of the fetal head through the maternal pelvis, reducing the risk of complications during labor. Station (A) refers to the level of the presenting part in the pelvis, descent (C) is the downward movement of the fetus, and engagement (D) is when the widest diameter of the fetal head passes through the maternal pelvic inlet. However, these factors do not specifically address the orientation of the fetal head to ensure the smallest diameter enters the pelvis.
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 because offering the patient a warm blanket helps prevent hypothermia, which can occur due to heat loss during the delivery process. This intervention promotes patient comfort and helps maintain their body temperature.
Choice B is incorrect because placing an ice pack on the perineum is typically done in the immediate postpartum period to reduce swelling and discomfort, not during the fourth stage of labor.
Choice C is incorrect because massaging the uterus if it is boggy is a postpartum intervention to prevent or treat uterine atony, not typically performed during the fourth stage of labor.
Choice D is incorrect because delaying breastfeeding until the patient is rested is not necessary during the fourth stage of labor. Breastfeeding should be initiated as soon as possible after delivery to promote bonding and stimulate milk production.
To determine if the patient is in true labor, the nurse would assess for changes in
- A. cervical dilation.
- B. amount of bloody show.
- C. fetal position and station.
- D. pattern of uterine contractions.
Correct Answer: D
Rationale: The correct answer is D: pattern of uterine contractions. This is because the pattern of contractions is a key indicator of true labor. True labor contractions are regular, increasing in frequency, duration, and intensity. Assessing the pattern helps differentiate true labor from false labor.
A: Cervical dilation is important but may not necessarily indicate true labor as it can occur in false labor as well.
B: The amount of bloody show is a sign of cervical changes, but it alone does not confirm true labor.
C: Fetal position and station are important for labor progress but do not definitively confirm true labor.
In summary, assessing the pattern of uterine contractions is crucial in determining true labor as it provides direct insight into the progression and intensity of contractions, distinguishing it from false labor.