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A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth?
- A. Eclampsia
- B. Placental abruption
- C. Congestive heart failure
- D. Uterine rupture
Correct Answer: D
Rationale: The main concern for VBAC is uterine rupture, which can disrupt placental blood flow and cause hemorrhage.
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The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?
- A. A well-oxygenated fetus
- B. Compression of the umbilical cord
- C. Compression of the fetal head
- D. Uteroplacental insufficiency
Correct Answer: A
Rationale: Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.
While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions?
- A. Provide for extreme modesty.
- B. Assign a male caregiver.
- C. Arrange for the husband/partner to participate in labor.
- D. Provide adequate pain control.
- E. Respect protective amulets.
Correct Answer: A,D,E
Rationale: Arab women are extremely modest, usually have a low pain tolerance, and wear protective amulets. Female caregivers are preferred, and the husband is present but not a participant.
The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
The nurse observes the patient bearing down with contractions and crying out, 'The baby is coming!' What is the best nursing intervention?
- A. Find the physician.
- B. Stay with the woman and use the call bell to get help.
- C. Send the woman's partner to locate a registered nurse.
- D. Assist with deep breathing to slow the labor process.
Correct Answer: B
Rationale: If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.
Why is the relaxation phase between contractions important?
- A. The laboring woman needs to rest.
- B. The uterine muscles fatigue without relaxation.
- C. The contractions can interfere with fetal oxygenation.
- D. The infant progresses toward delivery at these times.
Correct Answer: C
Rationale: Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.