Nokea
A laboring patient states to the nurse, "I have to push!” What is the next nursing action?
- A. Contact the health care provider.
- B. Examine the patient’s cervix for dilation.
- C. Review with her how to bear down with contractions.
- D. Ask her partner to support her head with each push.
Correct Answer: B
Rationale: The correct answer is B. Examining the patient's cervix for dilation is the next nursing action because it will help determine the progress of labor and assess if it is safe for the patient to push. Contacting the health care provider (choice A) may delay necessary interventions. Reviewing how to bear down (choice C) is important but assessing cervical dilation takes precedence. Asking the partner to support her head (choice D) is not a priority in this situation.
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A sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?
- A. Face presentation
- B. Breech presentation
- C. Vertex presentation
- D. Shoulder presentation
Correct Answer: A
Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) is the presenting part. The chin is the prominent part of the face, making it a face presentation. In a face presentation, the fetus is in a position where the head is extended rather than flexed. This can lead to complications during delivery.
Summary:
B: Breech presentation - In breech presentation, the baby's buttocks or feet are the presenting part.
C: Vertex presentation - In vertex presentation, the baby's head is the presenting part with the chin tucked towards the chest.
D: Shoulder presentation - In shoulder presentation, the baby is positioned transversely in the uterus with one or both shoulders presenting first.
A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?
- A. Notify the operating team of emergent cesarean delivery
- B. Assist the patient to left lateral position
- C. Apply O2 at 10-12 L/min per nonrebreather
- D. Administer an IV fluid bolus
Correct Answer: A
Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. In this scenario, the presence of bloody amniotic fluid and fetal heart rate decelerations to the 50s indicate potential fetal distress. Given the critical nature of this situation, an emergent cesarean delivery should be considered to expedite delivery and prevent further compromise to the fetus. This decision is based on the principle of prioritizing fetal well-being in situations of acute distress. Options B, C, and D do not address the immediate need for prompt intervention to ensure the safety of the fetus in distress.
A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Third stage
Correct Answer: B
Rationale: The correct answer is B: Active phase. In the active phase of labor, the cervix is typically dilated from 6 to 10 cm. This phase marks the transition from early labor to active labor, where contractions become stronger and more frequent, leading to further cervical dilation for the eventual delivery of the baby. The other choices are incorrect because:
A: Latent phase is typically from 0 to 6 cm dilation.
C: Second stage refers to the stage of labor starting from full dilation (10 cm) until the baby is born.
D: Third stage is the stage after the baby is born, focusing on the delivery of the placenta.
A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
- A. more rapid labor.
- B. a high risk of infection.
- C. maternal perineal traum
- D. umbilical cord compression.
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet are positioned to come out first, which can lead to potential umbilical cord compression during labor. This compression can compromise fetal oxygenation and circulation, posing a serious risk to the baby's well-being. The other choices are incorrect because a breech presentation is not typically associated with more rapid labor (choice A), a high risk of infection (choice B), or maternal perineal trauma (choice C). It is important for healthcare providers to be vigilant in monitoring for signs of umbilical cord compression in cases of breech presentation to ensure the safety of both the mother and baby.
Which physiologic event is the key indicator of the commencement of true labor?
- A. Bloody show
- B. Cervical dilation and effacement
- C. Fetal descent into the pelvic inlet
- D. Uterine contractions every 7 minutes
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation and effacement. This is the key indicator of true labor as it signifies the physiological changes needed for the cervix to open and thin out, allowing the baby to pass through the birth canal. Bloody show (A) can be present in early labor but is not a definitive sign. Fetal descent (C) and regular uterine contractions (D) are important, but cervical changes are the most reliable indicator of true labor initiation.