Nokea
A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
- A. There is no dilation.
- B. The contractions are in the fundus.
- C. The cervix has softened and effaced.
- D. The contractions are irregular.
Correct Answer: C
Rationale: One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic.
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Using Leopold maneuvers to assess fetal position the nurse finds a soft rounded prominence at the level of the fundus a hard round prominence just above the symphysis pubis and nodulations on the left side of the uterus. How should the nurse document the fetal position?
- A. Right occiput anterior (ROA) vertex
- B. Left occiput anterior (LOA) vertex
- C. Right occiput transverse (ROT) breech
- D. Left occiput anterior (LOA) breech
Correct Answer: A
Rationale: Fetal position can be determined by the Leopold maneuver, which defines the relationship of the presenting part to the maternal pelvis quadrant. A soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus indicate a right occiput anterior (ROA), vertex positioning.
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.
During labor the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
- A. Ask the husband to leave the room.
- B. Assure the husband that such behavior is normal.
- C. Remind the patient that the husband wants to help.
- D. Change the patient's position.
Correct Answer: B
Rationale: During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal.
What is the ideal attitude for the fetal body during labor?
- A. Extension
- B. Lateral
- C. Flexion
- D. Transverse
Correct Answer: C
Rationale: The ideal attitude for the fetal body is flexion.
Which type of monitor will assess the intensity of contractions?
- A. External monitor
- B. Fetal monitor
- C. Maternal monitor
- D. Internal monitor
Correct Answer: D
Rationale: Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity.