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A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?
- A. Perform a vaginal exam to assess for fetal position
- B. Prepare the patient for delivery
- C. Administer an epidural block
- D. Continue to monitor contractions and fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.
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What is the primary purpose of a vaginal examination during the second stage of labor?
- A. to assess fetal descent
- B. to evaluate uterine progress
- C. to assess cervical dilation
- D. to assess fetal position
Correct Answer: B
Rationale: The correct answer is B because during the second stage of labor, the primary purpose of a vaginal examination is to evaluate uterine progress. This is important to determine the effectiveness of contractions and the progression of labor. Assessing fetal descent (A) is typically done during the first stage of labor. Assessing cervical dilation (C) is important throughout labor but is not the primary purpose during the second stage. Assessing fetal position (D) can also be important but is not the primary focus during the second stage.
A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
- A. Cervical dilation
- B. Fetal position
- C. Fetal heart rate
- D. Maternal blood pressure
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing.
B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push.
C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push.
D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.
Which of the following is an appropriate intervention for a birthing person experiencing preterm labor?
- A. administer tocolytics
- B. administer antibiotics
- C. provide hydration and rest
- D. offer pain relief
Correct Answer: A
Rationale: The correct answer is A: administer tocolytics. Tocolytics help inhibit uterine contractions and can delay preterm labor, giving time for other interventions. Administering antibiotics (B) would not directly address preterm labor. Providing hydration and rest (C) may be helpful but not a direct intervention. Offering pain relief (D) does not address the underlying cause of preterm labor. Administering tocolytics is crucial in managing preterm labor to prevent premature birth and associated complications.
An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.
- A. Amenorrhea.
- B. Breast tenderness.
- C. Quickening.
- D. Frequent urination.
Correct Answer: A
Rationale: Presumptive signs of pregnancy are subjective and include amenorrhea, breast tenderness, quickening, and frequent urination. Uterine growth is a probable sign of pregnancy.
The nurse is educating a pregnant patient who is at 36 weeks gestation about the signs of labor. Which statement by the patient indicates effective teaching?
- A. I should report regular contractions that occur every 5 minutes for 1 hour.
- B. I should avoid drinking fluids until my contractions stop.
- C. If I lose my mucous plug, I should go to the hospital immediately.
- D. I should stay home and rest as long as my contractions are not painful.
Correct Answer: A
Rationale: The correct answer is A because reporting regular contractions occurring every 5 minutes for 1 hour is a key sign of active labor. This pattern indicates the onset of true labor and the need to seek medical attention.
Explanation:
1. Regular contractions every 5 minutes indicate active labor is likely.
2. Sustained contractions for an hour suggest progression of labor.
3. Seeking medical advice is crucial for appropriate management.
Incorrect Choices:
B. Incorrect. Staying hydrated is important during labor to prevent dehydration.
C. Incorrect. Losing the mucous plug is a sign of early labor, not an emergency.
D. Incorrect. Painful contractions are not the sole indicator of active labor; regularity is key.