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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. This is a definitive sign of true labor as it indicates that the cervix is opening up in preparation for childbirth. Contractions alone may not always indicate true labor, especially if they are irregular. Pain decreasing when walking (choice A) is not a definitive sign of true labor. The fetal membranes rupturing (choice C) is a sign of labor but not definitive on its own. The fetal head at –1 station (choice D) can indicate descent but is not as definitive as cervical dilation.
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A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Third stage
Correct Answer: B
Rationale: The correct answer is B: Active phase. In the active phase of labor, the cervix is typically dilated from 6 to 10 cm. This phase marks the transition from early labor to active labor, where contractions become stronger and more frequent, leading to further cervical dilation for the eventual delivery of the baby. The other choices are incorrect because:
A: Latent phase is typically from 0 to 6 cm dilation.
C: Second stage refers to the stage of labor starting from full dilation (10 cm) until the baby is born.
D: Third stage is the stage after the baby is born, focusing on the delivery of the placenta.
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.
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 correct answer is B because it describes the typical experiences of the birthing person during this stage. Cramping signifies uterine contractions, a gush of fresh vaginal bleeding indicates the delivery of the placenta, and lengthening of the umbilical cord indicates separation from the placenta. The other options are incorrect as they do not align with the physiological processes of the third stage of labor. A is incorrect as the fetus is delivered in the second stage, not the third. C is incorrect as dyspnea (difficulty breathing) is not a common symptom during the third stage. D is incorrect as increased blood pressure and pain are not typical experiences during this stage.
Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
- A. Extension
- B. Engagement
- C. Internal rotation
- D. External rotation
Correct Answer: B
Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part passes through the pelvic inlet, indicating the descent of the fetal head into the pelvis. This is a crucial step in labor progress as it signifies the baby's readiness for birth.
A: Extension occurs during the second stage of labor when the baby's head passes through the birth canal.
C: Internal rotation is the movement of the baby's head within the pelvis to align with the maternal pelvis.
D: External rotation happens after the baby's head is delivered to allow for the shoulders to rotate for birth.
In summary, engagement is the correct answer as it specifically refers to the largest diameter of the fetal presenting part passing the pelvic inlet, setting the stage for the progression of labor.
An infant was born 1 minute ago and the Apgar score is being assigned. The infant has blue extremities, minimal flexion, a weak cry, a heart rate of 110 beats per minute, and coughs and pulls away when suctioned. How many points should be assigned? Record your answer using a whole number:
- A. 3
- B. 2
- C. 1
Correct Answer: A
Rationale: The correct answer is A: 3 points. Apgar scoring assesses the newborn's overall condition at 1 and 5 minutes after birth. In this case, the infant's Apgar score should be 3 because the baby displays signs of mild distress with blue extremities, weak cry, and minimal flexion. The heart rate of 110 BPM and response to suctioning indicate some normal function. Each category (color, heart rate, reflex irritability, muscle tone, and respiratory effort) can score up to 2 points, totaling 10 points. Blue extremities and weak cry correspond to 1 point each, while minimal flexion corresponds to 0 points. The heart rate (110 BPM) and response to suctioning indicate 2 points each, totaling 3 points. Therefore, the correct score is 3 points. Choices B, C, and D are incorrect as they do not accurately reflect the severity of the infant's condition based on the Apgar