Nokea
A laboring patient asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
- A. The acme
- B. The interval
- C. The increment
- D. The decrement
Correct Answer: B
Rationale: The peak of a contraction, also known as its highest point or intensity, is referred to as the acme. This is the stage during which the contraction reaches its maximum strength before gradually subsiding. By identifying the acme of the contraction, healthcare providers can better gauge the progress of labor and assess the intensity of contractions to determine the appropriate course of action for the laboring patient.
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A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.)
- A. In true labor, the cervix begins to dilate
- B. In true labor, the contractions are felt in the abdomen and groin.
- C. In true labor, contractions often resemble menstrual cramps during early labor.
- D. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.
Correct Answer: A
Rationale: A. In true labor, the cervix begins to dilate: One of the key signs of true labor is that the cervix starts to dilate (open up) as the body prepares for childbirth. If a woman is experiencing real labor, her cervix will gradually start to open up to allow the baby to pass through the birth canal.
Cephalohematoma occurring from an operative vaginal delivery increased a newborn’s risk of developing which of the following complications?
- A. Bulging fontanels
- B. Developmental delays
- C. Jaundice
- D. Macrocephaly
Correct Answer: C
Rationale: Cephalohematomas are a common complication from operative vaginal deliveries. The accumulation of blood between the infant's skull and periosteum increases the risk of jaundice because of the breakdown of red blood cells, which can overwhelm the infant's immature liver and lead to hyperbilirubinemia.
How does becoming a parent cause the birthing person to feel?
- A. overwhelming feelings of joy or a sense of euphoria
- B. a wide variety of emotions specific to each person's experience
- C. overwhelming fear or sadness at the loss of their previous life
- D. exhausted with little interest the newborn
Correct Answer: B
Rationale: Becoming a parent can trigger a wide range of emotions that can vary from person to person. While feelings of joy and euphoria are commonly experienced, it is important to acknowledge that parenthood also brings about challenges, uncertainties, fears, and even feelings of loss or sadness. Each individual's background, personal experiences, support system, and circumstances play a significant role in shaping how they feel when they become a parent. It is normal for birthing persons to navigate through a mix of emotions as they adjust to their new role and responsibilities. Therefore, option B is the most appropriate choice as it recognizes the diverse emotional responses that can accompany the experience of becoming a parent.
The nurse is assessing the duration of a patient’s labor contractions. Which method does the nurse implement to assess the duration of labor contractions?
- A. Assess the strongest intensity of each contraction.
- B. Assess uterine relaxation between two contractions.
- C. Assess from the beginning to the end of each contraction.
- D. Assess from the beginning of one contraction to the beginning of the next.
Correct Answer: C
Rationale: The nurse implements method C, which involves assessing the duration of contractions from the beginning to the end of each contraction. Duration refers to how long each contraction lasts from the start of the tightening sensation until it subsides. This assessment helps the nurse monitor the progress of labor, determine the effectiveness of contractions in dilating the cervix, and identify any potential issues such as prolonged or insufficient contractions that may affect labor progression. Assessing the duration of contractions is a key component of monitoring the labor process and ensuring safe delivery for both the mother and the baby.
The nurse hears the laboring patient making grunting noises. How will the nurse determine if the person is in the active second stage of labor?
- A. Assess for rupture of membranes.
- B. Assess for bloody show.
- C. Assess for dilation of the cervix.
- D. Assess for stool.
Correct Answer: C
Rationale: In the active second stage of labor, the cervix is fully dilated to 10 centimeters. Grunting noises can be a sign of the transition to the pushing stage, which occurs in the active second stage of labor. Therefore, assessing for dilation of the cervix is crucial to determine if the laboring person is in the active second stage of labor.