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: The biparietal diameter of the fetal head is at the level of the ischial spines. Engagement of the fetal head occurs when the largest transverse diameter of the presenting part (usually the biparietal diameter) reaches or passes through the pelvic inlet, specifically at the level of the ischial spines. This signifies descent of the fetal head into the maternal pelvis, indicating progress towards labor.
Choice B (The biparietal diameter of the fetal head is at –2 station) is incorrect as station refers to the level of the presenting part in relation to the ischial spines, not engagement.
Choice C (The fetal head is well flexed) is incorrect as engagement does not necessarily indicate the position of the fetal head.
Choice D (The fetal head is unable to pass under the pubic arch) is incorrect as engagement actually signifies that the fetal head is in the optimal position to pass through the pelvis during labor.
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The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction?
- A. Little to no affect
- B. Increases as blood pressure decreases
- C. Diminishes as the spiral arteries are compressed
- D. Continues except when placental functions are reduced
Correct Answer: D
Rationale: The correct answer is D because maternal-fetal exchange of oxygen and waste products continues during uterine contractions unless placental functions are reduced. Contractions do not directly affect this exchange, so option A is incorrect. Option B is incorrect because blood pressure changes do not necessarily impact the exchange. Option C is incorrect because spiral arteries play a role in supplying blood to the placenta, but compression during contractions does not halt the exchange process.
During the third stage of labor, what may the birthing person experience?
- A. expulsion of their fetus with vaginal bleeding
- B. cramping, gush of fresh vaginal bleeding, lengthening of the umbilical cord
- C. frequent episodes of dyspnea
- D. increased blood pressure and pain due to expulsive efforts
Correct Answer: B
Rationale: During the third stage of labor, the birthing person may experience cramping, a gush of fresh vaginal bleeding, and lengthening of the umbilical cord. This is due to the delivery of the placenta. Cramping helps expel the placenta, fresh vaginal bleeding is normal after delivery, and the lengthening of the umbilical cord indicates that the placenta is detaching. Choices A, C, and D are incorrect as they do not accurately describe the typical experiences during the third stage of labor.
The nurse is caring for a patient during the first stage of labor. What is an abnormal finding?
- A. patient moaning with contractions
- B. contractions 3 minutes apart lasting 60 seconds
- C. blood pressure 142/88
- D. respiratory rate 22
Correct Answer: C
Rationale: The correct answer is C because a blood pressure of 142/88 is considered high and abnormal during the first stage of labor. This could indicate hypertension, which can have serious implications for both the mother and the baby. High blood pressure can lead to complications such as preeclampsia.
A, B, and D are incorrect because:
A: Patient moaning with contractions is a common response to labor pains and does not necessarily indicate an abnormal finding.
B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor.
D: A respiratory rate of 22 is also within the normal range and is not indicative of any abnormal findings during the first stage of labor.
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: A nitrazine test is the most conclusive test. The rationale for this is as follows:
1. Nitrazine test detects the pH level of the fluid. Amniotic fluid is alkaline while urine is acidic.
2. Amniotic fluid will turn the nitrazine paper blue, indicating a pH level greater than 6.5, while urine will not change the color significantly.
3. This test is reliable and can help differentiate between amniotic fluid and urine leakage.
Summary of other choices:
B: Although nitrazine paper changes color due to the acidic nature of amniotic fluid, it is not a comprehensive test on its own.
C: Ferning test is not commonly used in practice and may not be as reliable as the nitrazine test.
D: Noting if fluid is leaking from the perineal area does not provide a conclusive determination of whether it is amniotic fluid or urine.
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.