Nokea
An infant presents 5 minutes after delivery with a heart rate of 105 crying has some flexion in the arms sneezes and has a pink body and blue limbs. What Apgar score should be assigned to this infant?
- A. 5
- B. 7
- C. 8
- D. 10
Correct Answer: C
Rationale: The Apgar scoring is: fetal heart rate (FHR) over 100 = 2; crying = 2; flexed arms = 1; sneeze = 2; pink body, blue limbs = 1.
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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.
A woman is admitted in active labor and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment?
- A. Position patient on her left side.
- B. Start oxygen per nasal cannula.
- C. Reassure the mother the rate is normal.
- D. Notify the health care provider at once.
Correct Answer: C
Rationale: The normal FHR is 120 to 160 beats/min. No interventions are required.
Why is the size and shape of the true pelvis more important than that of the false pelvis?
- A. The fetal head must be able to pass through the true pelvis.
- B. The true pelvis are the mother's measurements.
- C. The size of the false pelvis can change.
- D. The size of the true pelvis needs to be larger.
Correct Answer: A
Rationale: The size and shape of the true pelvis is more important than the false pelvis because the fetal head must be able to pass through for vaginal delivery to occur.
When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured the paper turns yellow. What does this finding indicate?
- A. Acidic discharge membranes intact
- B. Acidic discharge membranes have ruptured
- C. Neutral not enough discharge to measure
- D. Alkaline membranes have ruptured
Correct Answer: A
Rationale: When the Nitrazine paper turns yellow it is indicative of acidic discharge, meaning the membranes are intact. Amniotic fluid is alkaline and turns the paper blue.
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.