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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The nurse has just performed a sterile vaginal examination on her patient and reports the examination as 4 cm, 50%, –1. What does this represent?
- A. Effacement, station, and dilation
- B. Dilation, station, and fetal lie
- C. Dilation, effacement, and status of membranes
- D. Dilation, effacement, and station
Correct Answer: D
Rationale: The examination reflects the dilation, effacement, and station of the cervix.
If the fetal attitude is assessed to be completely deflexed on sonogram or via Leopold's maneuvers, what presenting part do you anticipate palpating in a vaginal exam?
- A. brow
- B. breech
- C. face
- D. occiput
Correct Answer: D
Rationale: If the fetal attitude is assessed to be completely deflexed on sonogram or via Leopold's maneuvers, it means the baby is presenting in an extended position with the occiput being the lead point of the presenting part during a vaginal exam. This position is known as occiput posterior. The fetal occiput is the back of the head, and it is the optimal position for vaginal delivery as the smallest diameter of the baby's head will be presenting at the cervix, facilitating an easier descent through the birth canal.
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.
A woman has chosen a trial of labor after cesarean. Which findings indicate the best understanding of the nurse’s teaching by the patient?
- A. "It is safer for me to be induced at 39 weeks so that my labor can be controlled and monitored carefully.”
- B. "I will need to arrive to the hospital the night before my induction so that my cervix can be ripened with prostaglandins.”
- C. "If I do not go into labor on my own, I will have to have a cesarean section since Pitocin is contraindicated for me.”
- D. "A balloon catheter may be used to manually ripen my cervix, if necessary”
Correct Answer: D
Rationale: The correct understanding is that cervical ripening may be necessary before induction, and a balloon catheter can be used for this purpose. This is part of the education provided to patients who opt for a trial of labor after cesarean.
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.