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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. During true labor, the cervix begins to dilate and efface in preparation for childbirth. This process is a definitive sign of active labor. In contrast, the other choices are not definitive signs of true labor. Choice A is incorrect because pain decreasing when walking is not a specific indicator of true labor. Choice C, the fetal membranes rupturing, indicates the beginning of labor but is not the definitive sign. Choice D, the fetal head at –1 station, signifies the descent of the baby into the pelvis but does not confirm active labor.
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A laboring patient states to the nurse, "I have to push!” What is the next nursing action?
- A. Contact the health care provider.
- B. Examine the patient’s cervix for dilation.
- C. Review with her how to bear down with contractions.
- D. Ask her partner to support her head with each push.
Correct Answer: B
Rationale: The correct answer is B: Examine the patient’s cervix for dilation. This is the next nursing action because assessing cervical dilation is crucial in determining the progress of labor and if the patient is ready to push effectively. Contacting the health care provider (A) may cause unnecessary delays. Reviewing how to bear down with contractions (C) should be done after confirming cervical dilation. Asking her partner to support her head (D) is not the immediate priority in this situation.
A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
- A. more rapid labor.
- B. a high risk of infection.
- C. maternal perineal traum
- D. umbilical cord compression.
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet are positioned to come out first, which can lead to potential umbilical cord compression during labor. This compression can compromise fetal oxygenation and circulation, posing a serious risk to the baby's well-being. The other choices are incorrect because a breech presentation is not typically associated with more rapid labor (choice A), a high risk of infection (choice B), or maternal perineal trauma (choice C). It is important for healthcare providers to be vigilant in monitoring for signs of umbilical cord compression in cases of breech presentation to ensure the safety of both the mother and baby.
A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?
- A. Notify the operating team of emergent cesarean delivery
- B. Assist the patient to left lateral position
- C. Apply O2 at 10-12 L/min per nonrebreather
- D. Administer an IV fluid bolus
Correct Answer: A
Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. In this scenario, the presence of bloody amniotic fluid and fetal heart rate decelerations to the 50s indicate potential fetal distress. Given the critical nature of this situation, an emergent cesarean delivery should be considered to expedite delivery and prevent further compromise to the fetus. This decision is based on the principle of prioritizing fetal well-being in situations of acute distress. Options B, C, and D do not address the immediate need for prompt intervention to ensure the safety of the fetus in distress.
When caring for a woman with a complete placenta previa, which finding should the nurse report to the physician?
- A. BP of 95/60
- B. Temperature of 100.1°F
- C. Urine output of 40 mL/hour
- D. O2 saturation less that 95%
Correct Answer: D
Rationale: The correct answer is D: O2 saturation less than 95%. In placenta previa, the placenta covers the cervix, increasing the risk of bleeding. Decreased oxygen saturation can indicate poor perfusion due to bleeding, necessitating immediate medical attention. A: BP of 95/60 is relatively normal and not an urgent concern in this scenario. B: Temperature of 100.1°F may indicate an infection but is not directly related to placenta previa. C: Urine output of 40 mL/hour is within the normal range and does not directly impact the management of placenta previa.
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.