Nokea
A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when?
- A. The cervix is completely effaced.
- B. The baby is in position.
- C. The cervix is fully dilated.
- D. The woman begins pushing.
Correct Answer: C
Rationale: The first stage of labor begins with regular contractions and ends with complete dilation of the cervix.
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How do Braxton-Hicks contractions differ from labor contractions?
- A. Last several minutes.
- B. Are always regular.
- C. Do not dilate the cervix.
- D. Are only mild.
Correct Answer: C
Rationale: Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can range from mild to moderate in severity, and increase in duration as the pregnancy progresses.
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
- A. Cool fluids to drink
- B. A backrub in the sacral area
- C. Assisting to lie in a supine position
- D. Decreasing illumination in the room
Correct Answer: B
Rationale: Backache in the sacral area is a common complaint during the first stage of labor. The keyword is "comfort" in the question. Providing a backrub is providing comfort to the laboring patient.
When observing the fetal heart monitor the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
- A. Early deceleration due to head compression
- B. That the fetus is in acute distress
- C. Variable decelerations due to cord compression
- D. That these are late decelerations
Correct Answer: A
Rationale: This indicates early decelerations because of head compression.
For the first hour following delivery how often should the nurse assess the mother?
- A. Every 5 minutes
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: During the first hour, assessments are done every 15 minutes.
A woman who is 38 weeks' pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
- A. Lightening
- B. Braxton-Hicks contractions
- C. Initiation of labor
- D. Engagement
Correct Answer: A
Rationale: The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally.