Nokea
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
- A. contraction pattern, amount of discomfort, and pregnancy history.
- B. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
- C. last food intake, when labor began, and cultural practices the couple desires.
- D. identification of ruptured membranes, the woman's gravida and para, and access to a support person.
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions.
A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period.
C is incorrect as last food intake and cultural practices are not the most critical assessments during labor.
D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
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Which of the following factors would affect pain perception or tolerance for the laboring patient?
- A. Right occiput posterior fetal position during labor
- B. Bishop score of 10 prior to the induction of labor
- C. Gynecoid pelvis
- D. Absence of Ferguson's reflex
Correct Answer: A
Rationale: The correct answer is A: Right occiput posterior fetal position during labor. This position can lead to intense back pain and prolonged labor, affecting pain perception. A posterior position can put pressure on the sacrum and cause increased discomfort. In contrast, choices B, C, and D do not directly impact pain perception during labor. Choice B, Bishop score of 10, indicates favorable conditions for labor progress but does not necessarily affect pain perception. Choice C, Gynecoid pelvis, refers to a common pelvis shape that may facilitate labor but does not directly influence pain tolerance. Choice D, Absence of Ferguson's reflex, is related to the ability to push effectively but is not directly linked to pain perception.
A maternal indication for the use of vacuum extraction is
- A. a wide pelvic outlet.
- B. maternal exhaustion.
- C. a history of rapid deliveries.
- D. failure to progress past 0 station.
Correct Answer: B
Rationale: The correct answer is B: maternal exhaustion. Vacuum extraction may be indicated when the mother is too exhausted to continue pushing, as it can assist in the delivery process. A wide pelvic outlet (choice A) may facilitate delivery but is not a specific indication for vacuum extraction. A history of rapid deliveries (choice C) does not necessarily require vacuum extraction. Failure to progress past 0 station (choice D) may indicate other interventions like cesarean section rather than vacuum extraction. Therefore, the most appropriate indication for vacuum extraction in this scenario is maternal exhaustion.
What are the side effects of spinal anesthesia? Select one that doesn't apply.
- A. hypotension
- B. respiratory depression
- C. renal damage
- D. infection
Correct Answer: C
Rationale: The correct answer is C: renal damage. Spinal anesthesia affects the nervous system, not the kidneys. Hypotension and respiratory depression are common side effects due to vasodilation and decreased respiratory drive. Infection can occur due to the invasive nature of the procedure. Renal damage is not a known side effect of spinal anesthesia as it does not directly affect kidney function.
Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?
- A. Elevated pulse rate
- B. Elevated blood pressure
- C. Firm fundus at the midline
- D. Saturation of two perineal pads in 4 hours
Correct Answer: D
Rationale: The correct answer is D. Saturation of two perineal pads in 4 hours is an indication of hemorrhage postpartum. This is because excessive bleeding after delivery can lead to soaking through pads quickly. A: Elevated pulse rate can be a sign of shock but not specific to hemorrhage. B: Elevated blood pressure is not a typical sign of hemorrhage. C: A firm fundus at the midline is a normal finding postpartum and not indicative of hemorrhage.
The nurse is teaching a childbirth education class. Which information regarding excessive pain in labor should the nurse include in the session?
- A. It usually results in a more rapid labor.
- B. It has no effect on the outcome of labor.
- C. It is considered to be a normal occurrenc
- D. It may result in decreased placental perfusion.
Correct Answer: D
Rationale: The correct answer is D because excessive pain in labor can lead to increased maternal stress, which may result in decreased placental perfusion, compromising oxygen and nutrient delivery to the fetus. This can have serious implications for the baby's well-being. Choices A, B, and C are incorrect because excessive pain in labor does not necessarily lead to a more rapid labor, has an effect on the labor outcome by potentially impacting placental perfusion, and is not considered a normal occurrence that should be disregarded.