Nokea
A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.)
- A. In true labor, the cervix begins to dilate
- B. In true labor, the contractions are felt in the abdomen and groin.
- C. In true labor, contractions often resemble menstrual cramps during early labor.
- D. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.
Correct Answer: A
Rationale: A. In true labor, the cervix begins to dilate: One of the key signs of true labor is that the cervix starts to dilate (open up) as the body prepares for childbirth. If a woman is experiencing real labor, her cervix will gradually start to open up to allow the baby to pass through the birth canal.
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Which clinical finding should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)
- A. A gush of blood appears.
- B. The uterus rises upward in the abdomen.
- C. The fundus descends below the umbilicus.
- D. The cord descends further from the vagin
Correct Answer: C
Rationale: A. A gush of blood appears: This clinical finding is indicative of the placenta detaching from the uterine wall and the subsequent expulsion. The sudden release of a significant amount of blood is expected as the placenta separates.
Uncontrolled maternal hyperventilation during labor results in
- A. metabolic acidosis.
- B. metabolic alkalosis.
- C. respiratory acidosis.
- D. respiratory alkalosis.
Correct Answer: D
Rationale: Uncontrolled maternal hyperventilation during labor leads to excessive elimination of carbon dioxide, causing a decrease in the partial pressure of arterial carbon dioxide (PaCO2). This results in respiratory alkalosis, as the pH of the blood increases due to a decrease in PaCO2. Metabolic acidosis (Option A) would be associated with conditions such as lactic acidosis, while metabolic alkalosis (Option B) would involve excessive loss of acid or gain of base, but in this case, the primary effect is on the respiratory system. Respiratory acidosis (Option C) would be characterized by an increase in PaCO2 leading to a decrease in pH, which is the opposite of what occurs in maternal hyperventilation.
The onset of labor is multifactorial. These reasons include which of the following? Select all that apply.
- A. Increase in progesterone
- B. Increase in estrogen
- C. Increase in human chorionic gonadotropin
- D. Aging of placenta
Correct Answer: B
Rationale: Increase in progesterone, estrogen, aging of placenta, and fetal hormones are the factors contributing to the onset of labor.
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.
Which maternal factor may inhibit fetal descent during labor?
- A. A full bladder
- B. Decreased peristalsis
- C. Rupture of membranes
- D. Reduction in internal uterine size
Correct Answer: A
Rationale: A full bladder can inhibit fetal descent during labor by obstructing the pathway for the baby to descend through the birth canal. A distended bladder can physically block the baby's head from moving down and putting pressure on the cervix, which is necessary for the progress of labor. It is important for pregnant individuals to empty their bladder regularly during labor to optimize the conditions for fetal descent and facilitate a smoother delivery process.