Nokea
A nurse is assessing a laboring person's progress. What is the most reliable indicator that the laboring person is in the active phase of labor?
- A. Progressive cervical dilation
- B. Frequent, regular contractions
- C. Fetal descent
- D. Effacement of the cervix
Correct Answer: A
Rationale: The correct answer is A: Progressive cervical dilation. This is the most reliable indicator of the active phase of labor because it directly reflects the opening of the cervix, indicating that labor is advancing. Cervical dilation is a key aspect of labor progress and is used to determine the stage of labor. Frequent, regular contractions (choice B) are important but can occur in early labor as well. Fetal descent (choice C) is an important aspect but may happen in conjunction with cervical dilation. Effacement of the cervix (choice D) is also important but does not solely indicate the active phase of labor.
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A gravid woman and her husband inform the nurse that they have just moved into a three-story home that was built in the 1930s. Which of the following is critical for the nurse to advise the woman to protect the unborn child?
- A. Stay out of any rooms that are being renovated.
- B. Drink water only from the hot water tap.
- C. Refrain from entering the basement.
- D. Climb the stairs only once per day.
Correct Answer: A
Rationale: Renovations in older homes may release lead dust or asbestos, which are harmful to the developing fetus. Drinking water from the hot tap, limiting stair climbing, or avoiding basements are less critical concerns compared to exposure to renovation hazards.
What response is appropriate regarding sushi consumption during pregnancy?
- A. Fish is healthy
- B. Sushi is too salty
- C. Raw fish is high in mercury
- D. Fish should be cooked
Correct Answer: D
Rationale: Cooking fish destroys harmful bacteria and parasites, reducing the risk of foodborne illnesses during pregnancy.
A 40-year-old primiparous woman who is 38 weeks pregnant has been on the labor unit for an hour when she starts to complain of feeling dizzy, light-headed, and nauseous. Her blood pressure is 90/60. What should be the first response of the nurse?
- A. Give the patient a bolus of intravenous fluid.
- B. Turn the patient to her left side.
- C. Call the obstetrician or nurse midwife.
- D. Give the patient an antiemetic medication for the nausea.
Correct Answer: B
Rationale: The correct answer is B: Turn the patient to her left side.
Rationale:
1. The patient's symptoms of dizziness, light-headedness, and low blood pressure (90/60) suggest hypotension, which could be due to supine hypotensive syndrome in pregnancy.
2. Turning the patient to her left side can help alleviate pressure on the vena cava, improving blood flow back to the heart and subsequently increasing blood pressure.
3. This immediate action can help prevent further complications such as decreased placental perfusion and fetal distress.
Summary:
- Choice A (Give the patient a bolus of intravenous fluid): While IV fluids may be needed, the priority is to address the underlying cause of hypotension first.
- Choice C (Call the obstetrician or nurse midwife): While it is important to involve the healthcare provider, immediate action to address the hypotension is crucial.
- Choice D (Give the patient an antiemetic medication for
The nurse is assessing the laboratory report of a 40-week gestation client. Which of the following values would the nurse expect to find elevated above prepregnancy levels? Select all that apply.
- A. Glucose.
- B. Fibrinogen.
- C. Hematocrit.
- D. Bilirubin.
Correct Answer: B
Rationale: Fibrinogen levels increase to prevent excessive blood loss during delivery, and white blood cell count rises to protect against infection. Glucose, hematocrit, and bilirubin levels should remain within normal limits.
The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination.
- A. Orthopneic.
- B. Lateral-recumbent.
- C. Sims'.
- D. Semi-Fowler’s.
Correct Answer: B
Rationale: The lateral-recumbent position reduces pressure on the inferior vena cava and is safer for pregnant women compared to other positions.