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A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
- A. more rapid labor.
- B. a high risk of infection.
- C. maternal perineal traum
- D. umbilical cord compression.
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet are positioned to come out first, which can lead to potential umbilical cord compression during labor. This compression can compromise fetal oxygenation and circulation, posing a serious risk to the baby's well-being. The other choices are incorrect because a breech presentation is not typically associated with more rapid labor (choice A), a high risk of infection (choice B), or maternal perineal trauma (choice C). It is important for healthcare providers to be vigilant in monitoring for signs of umbilical cord compression in cases of breech presentation to ensure the safety of both the mother and baby.
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A woman who is 39 weeks pregnant presents to the labor and delivery unit stating that she thinks she is in labor. Her contractions are irregular at 7 to 10 minutes apart. Which sign is definitive for true labor?
- A. Pain decreases when walking.
- B. Cervical dilation is occurring.
- C. The fetal membranes rupture.
- D. The fetal head is at –1 station.
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation is occurring. This is a definitive sign of true labor as it indicates that the cervix is opening up in preparation for childbirth. Contractions alone may not always indicate true labor, especially if they are irregular. Pain decreasing when walking (choice A) is not a definitive sign of true labor. The fetal membranes rupturing (choice C) is a sign of labor but not definitive on its own. The fetal head at –1 station (choice D) can indicate descent but is not as definitive as cervical dilation.
A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
- A. A nitrazine test is the most conclusive test.
- B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.
- C. Ferning is more conclusive than nitrazine paper testing.
- D. Note if there is fluid leaking from the perineal area.
Correct Answer: A
Rationale: The correct answer is A. The nurse should perform a nitrazine test to determine if the fluid leaking is amniotic fluid. Here's the rationale:
1. Nitrazine test is specifically designed to differentiate amniotic fluid from urine.
2. Amniotic fluid is alkaline, causing the nitrazine paper to turn blue when it comes into contact with it.
3. Urine, on the other hand, does not change the color of the nitrazine paper.
4. This test is quick, easy to perform, and provides a conclusive result in differentiating amniotic fluid from other fluids.
In summary:
- Choice B incorrectly describes the color change mechanism of nitrazine paper.
- Choice C refers to ferning, which is not as conclusive as the nitrazine test.
- Choice D does not provide a definitive method for determining if the leaking fluid is amniotic fluid.
When does the second stage of labor begin?
- A. at birth
- B. when the early phase ends
- C. when the cervix is completely dilated and effaced
- D. when pushing begins
Correct Answer: D
Rationale: The correct answer is D: when pushing begins. The second stage of labor begins when the cervix is fully dilated, and the mother starts pushing to deliver the baby. This stage ends with the birth of the baby. Option A is incorrect because the second stage begins after birth. Option B is incorrect as it refers to the transition phase, not the second stage. Option C is incorrect because the cervix being fully dilated and effaced marks the beginning of the second stage, not the end of it.
The nurse is caring for a laboring patient with multiple family members in the room. How can the nurse address this situation?
- A. Educate the family that the pain the laboring person is experiencing is normal.
- B. Ask them all to leave the room.
- C. Explain that if the laboring person got an epidural, she would be more comfortable
- D. Assume the laboring person wants the family in the room
Correct Answer: B
Rationale: The correct answer is B, asking all family members to leave the room. This is important to provide privacy, reduce distractions, and maintain the laboring person's comfort and focus. Educating the family on pain normalcy (A) is secondary to the laboring person's immediate needs. Suggesting an epidural (C) without the laboring person's consent is inappropriate. Assuming the laboring person wants the family in the room (D) disregards the individual's preferences and comfort.
Which is the cervical exam that most indicates the use of misoprostol?
- A. 1 cm dilated, 20% effaced, -3 station, firm and posterior
- B. 3-4 cm dilated, 50% effaced, -2 station, firm and midposition
- C. 5 cm dilated, 80% effaced, 0 station, soft and midposition
- D. 6 cm dilated, 100% effaced, +1 station, soft and anterior
Correct Answer: A
Rationale: The correct answer is A: 1 cm dilated, 20% effaced, -3 station, firm and posterior. Misoprostol is commonly used for cervical ripening in preparation for labor induction. This choice indicates an unfavorable cervix, which would benefit from cervical ripening agents like misoprostol. The cervix is minimally dilated (1 cm), partially effaced (20%), high (-3 station), firm, and posterior. This profile suggests that the cervix is not yet ripe and may require assistance in ripening for labor induction.
Choice B: 3-4 cm dilated, 50% effaced, -2 station, firm and midposition - this indicates a more favorable cervix for labor and would not typically require misoprostol for cervical ripening.
Choice C: 5 cm dilated, 80% effaced, 0 station, soft and midposition - this indicates an even more favorable cervix for labor,