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A nurse is caring for a laboring person and is monitoring for signs of fetal distress. Which finding is the most concerning in this situation?
- A. Late decelerations
- B. Bradycardia
- C. Tachycardia
- D. Variable decelerations
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can lead to fetal hypoxia and distress. This is the most concerning finding as it indicates a problem with oxygen delivery to the fetus. Bradycardia (B) and Tachycardia (C) can also be concerning, but late decelerations are more specific to fetal distress. Variable decelerations (D) are caused by cord compression and are concerning but not as indicative of fetal distress as late decelerations.
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A nurse is caring for a laboring person who is in the third stage of labor. What is the most appropriate nursing intervention during this stage?
- A. assist with the delivery of the placenta
- B. prepare for a vaginal birth
- C. administer oxytocin
- D. apply gentle pressure to the uterus
Correct Answer: A
Rationale: The correct answer is A: assist with the delivery of the placenta. During the third stage of labor, the placenta needs to be delivered. This is done by gently applying traction to the umbilical cord while supporting the uterus to facilitate the expulsion of the placenta. This step is crucial to prevent postpartum hemorrhage.
Choice B (prepare for a vaginal birth) is incorrect because the person is already in the third stage of labor, which means the baby has been delivered and they are now focusing on delivering the placenta.
Choice C (administer oxytocin) is incorrect because while oxytocin may be used to help control bleeding after the placenta is delivered, it is not the most appropriate intervention during the third stage of labor.
Choice D (apply gentle pressure to the uterus) is incorrect because direct pressure to the uterus is not the primary intervention during the third stage of labor; assisting with the delivery of the placenta takes precedence.
A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits?
- A. Leg cramps.
- B. Varicose veins.
- C. Hemorrhoids.
- D. Fainting spells.
Correct Answer: A
Rationale: Leg cramps, varicose veins, and hemorrhoids are common complaints during pregnancy due to increased blood volume and pressure on the lower extremities. Fainting spells are not considered normal and may indicate an underlying issue.
The vessels comprising the umbilical cord are cushioned and protected by a substance called _____________ _____________.
- A. Wharton’s jelly
- B. Endoderm
- C. jelly
- D. haploid
Correct Answer: A
Rationale: Wharton’s jelly is a gelatinous substance surrounding the blood vessels in the umbilical cord. It cushions and protects the vessels from compression and damage during pregnancy.
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. When is the best time for the nurse to schedule the patient’s ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: An ultrasound at around 5-6 weeks after the last menstrual period is the most accurate time to determine gestational age.
In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
- A. every 5 minutes with contractions
- B. at least every 30 minutes
- C. every 5–15 minutes
- D. only when the physician orders assessment
Correct Answer: C
Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.