Nokea
A primigravida patient is admitted to the labor and delivery unit. During initial assessment the baby is found to be engaged. Which statement is true?
- A. The narrowest diameter of the presenting part has reached the pelvic outlet.
- B. The descending part is being initiated through the midpelvis.
- C. The widest diameter of the presenting part crosses the pelvic inlet.
- D. The narrowest diameter of the presenting part is at the ischial spines.
Correct Answer: C
Rationale: Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet.
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A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
- A. There is no dilation.
- B. The contractions are in the fundus.
- C. The cervix has softened and effaced.
- D. The contractions are irregular.
Correct Answer: C
Rationale: One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic.
A nurse is teaching a group of primigravidas that during delivery pressure on the fetal skull may produce changes in the shape of the skull. What is the reshaping of the skull called?
- A. Pressure response
- B. Overlapping
- C. Molding
- D. Spacing
Correct Answer: C
Rationale: The reshaping of the skull bones in response to pressure is called molding.
After the delivery of a newborn what is the priority action of the nurse?
- A. Place the newborn on the right side.
- B. Cover the cord stump.
- C. Dry the infant immediately.
- D. Suction nose and mouth.
Correct Answer: D
Rationale: To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent hypothermia.
The nurse is trying to differentiate true labor from false labor. Which of the following is correct regarding true labor?
- A. Discomfort of the contraction is in the fundus.
- B. Contractions do not follow a pattern.
- C. Contractions get stronger with ambulation.
- D. Contractions may stop with ambulation.
Correct Answer: C
Rationale: Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions.
For the first hour following delivery how often should the nurse assess the mother?
- A. Every 5 minutes
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: During the first hour, assessments are done every 15 minutes.