Nokea
A woman who is 38 weeks' pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
- A. Lightening
- B. Braxton-Hicks contractions
- C. Initiation of labor
- D. Engagement
Correct Answer: A
Rationale: The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally.
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The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment which assessment is the priority?
- A. The number of previous pregnancies
- B. When the baby is due
- C. When the patient last ate
- D. The timing of contractions
Correct Answer: D
Rationale: Assessment begins with timing the contractions on admission to form a database.
Which type of monitor will assess the intensity of contractions?
- A. External monitor
- B. Fetal monitor
- C. Maternal monitor
- D. Internal monitor
Correct Answer: D
Rationale: Internal monitoring is used to monitor the intensity of contractions, the frequency and duration of contractions, and the resting tone of uterine contractions. An external monitor is used to monitor the fetal heart rate and uterine activity.
A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mother's to demonstrate a ___ lie.
Correct Answer: longitudinal
Rationale: A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other.
During the second stage of labor how often should the nurse monitor the fetal heart rate?
- A. Every 5 minutes
- B. Every 15 minutes
- C. Every 30 minutes
- D. Every hour
Correct Answer: A
Rationale: Fetal heart rate should be assessed every 5 minutes during the second stage of labor.
During labor the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
- A. Ask the husband to leave the room.
- B. Assure the husband that such behavior is normal.
- C. Remind the patient that the husband wants to help.
- D. Change the patient's position.
Correct Answer: B
Rationale: During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal.