Nokea
A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
- A. The biparietal diameter of the fetal head is at the level of the ischial spines.
- B. The biparietal diameter of the fetal head is at –2 station.
- C. The fetal head is well flexed.
- D. The fetal head is unable to pass under the pubic arch.
Correct Answer: A
Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.
You may also like to solve these questions
The nurse is caring for a gravida 5, para 4 who has been 5 centimeters dilated for 2 hours. The uterine contractions are every 5 minutes and mild to palpation. Which is the most appropriate nursing action?
- A. Administer ordered IV pain medicine
- B. Assist the patient with frequent position changes
- C. Prepare patient for epidural anesthesia
- D. Prepare patient for a cesarean section delivery
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with frequent position changes. This is the most appropriate nursing action because the patient is already in active labor (5 cm dilated), experiencing regular contractions, and has mild pain. Encouraging position changes can help progress labor by promoting optimal fetal positioning and descent, relieving pressure on the cervix, and enhancing uterine contractions. This can potentially shorten labor duration and reduce the risk of complications. Administering IV pain medicine (choice A) is not necessary at this stage as the pain is mild. Preparing for epidural anesthesia (choice C) is premature for mild pain and can slow down labor. Preparing for a cesarean section delivery (choice D) is not indicated at this point as the patient is progressing in labor.
A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?
- A. Perform a vaginal examination to determine cervical dilation
- B. Assist the health care provider to perform artificial rupture of the membranes
- C. Initiate external fetal monitoring
- D. Encourage patient to ambulate to intensify labor
Correct Answer: C
Rationale: The correct answer is C: Initiate external fetal monitoring. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.
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.