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.
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How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?
- A. Invite the family to come in and see the newborn.
- B. Take the lead from the parents regarding interruption of the bonding.
- C. Ask multiple questions about taking pictures of the newborn.
- D. Take the newborn to the nursery to encourage the parents to rest.
Correct Answer: B
Rationale: The correct answer is B. In the fourth stage of labor, the nurse should respect the rapid psychologic changes by taking the lead from the parents regarding interruption of bonding. This is important because it allows the parents to establish a strong bond with their newborn without feeling pressured or rushed. By following the parents' cues, the nurse can support their emotional needs and facilitate a positive bonding experience.
Choices A, C, and D are incorrect because they do not prioritize the parents' emotional needs and may disrupt the bonding process. Inviting the family to see the newborn (Choice A) may add stress to the situation. Asking multiple questions about taking pictures (Choice C) may be intrusive. Taking the newborn to the nursery (Choice D) may interfere with the bonding process and discourage parental involvement.
Which of the following is a function of a doula during labor?
- A. Administration of oral pain medications
- B. Assess fetal heart rate
- C. Perform vaginal examination with the mother’s permission
- D. Provide nonpharmacological pain relief
Correct Answer: D
Rationale: The correct answer is D. A doula provides nonpharmacological pain relief during labor by offering emotional support, comfort measures, breathing techniques, and massage. This helps the mother cope with labor pain naturally. Choices A and C involve medical interventions that are typically performed by healthcare providers. Choice B is the role of a healthcare professional trained in assessing fetal well-being.
If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the
- A. head is in the right posterior quadrant of the pelvis.
- B. head is in the left anterior quadrant of the pelvis.
- C. buttocks are in the left posterior quadrant of the pelvis.
- D. buttocks are in the right upper quadrant of the abdomen.
Correct Answer: C
Rationale: The correct answer is C because LSP stands for Left Sacrum Posterior, meaning the baby's back is on the left side of the mother's spine and facing towards her back. This position is common during the early stages of labor. Choice A is incorrect as it describes a different position, choice B is incorrect as it refers to a different quadrant, and choice D is incorrect as it describes a location in the abdomen, not the pelvis.
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.
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.