Nokea
A nurse performs a vaginal examination on her patient in early labor and determines that the head is ballotable. What is this defined as?
- A. Floating
- B. Zero station
- C. +1 station
- D. -2 station
Correct Answer: A
Rationale: Ballotable means the fetal head is floating and can be pushed away from the cervix.
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An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an indication of
- A. lightening.
- B. breech presentation.
- C. urinary tract infection.
- D. onset of Braxton-Hicks contractions.
Correct Answer: A
Rationale: An increase in urinary frequency and leg cramps after the 36th week of pregnancy are common signs of "lightening." Lightening refers to the descent of the baby into the pelvis in preparation for labor. This shift in position can put pressure on the bladder, leading to increased urinary frequency. Additionally, the pressure on nerves and blood vessels in the pelvis can cause leg cramps. These symptoms are typically experienced in the final weeks of pregnancy and are considered normal signs that the body is preparing for labor.
The nurse is caring for a patient during induction of labor. The oxytocin is currently infusing at 6 mU/min. The fetal heart tracing displays a 130 baseline, moderate variability, and no accelerations or decelerations. Uterine contractions have been every 2 minutes for the last 30 minutes. What is the nurse’s next best action?
- A. Reduce the oxytocin infusion to 3 mU/min
- B. Delay the next scheduled oxytocin increase
- C. Maintain infusion at 6 mU/min
- D. Discontinue the oxytocin infusion
Correct Answer: C
Rationale: The fetal heart rate (FHR) is stable, with moderate variability and no decelerations, indicating that the fetus is not in distress. The contractions are occurring at appropriate intervals, so the nurse should maintain the current oxytocin infusion to continue labor progression.
While attending the delivery of a patient with GODM, the nurse notices the retraction of the fetal head onto the perineum. What is the nurse’s next best action?
- A. Apply fundal pressure
- B. Assist the woman to left lateral position
- C. Flex the mother to left lateral position
- D. Assist the woman to hands-and-knees position
Correct Answer: D
Rationale: The retraction of the fetal head onto the perineum during labor can be indicative of shoulder dystocia or other obstructive complications, requiring immediate action. The best response is to assist the mother into hands-and-knees position, which can relieve pressure on the perineum and help with fetal descent.
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.
Which is the best explanation for the use of hydration and relaxation in the treatment of hypertonic labor?
- A. Hydration promotes uterine relaxation by diluting endogenous oxytocin.
- B. Hydration improves uterine coordination by increasing perfusion.
- C. Hydration encourages contraction regulation by stimulating catecholamine release.
- D. Hydration stimulates the production of prostaglandins to relax the uterus.
Correct Answer: A
Rationale: Hydration helps to dilute endogenous oxytocin, which can reduce uterine contractions and relax the uterus. Hypertonic labor involves excessive uterine contractions, and hydration can counteract this by regulating contractions and improving perfusion, which ultimately aids in a more coordinated and effective labor progression.