Nokea
At 1 and 5 minutes of life, a newborn's Apgar score is 9. What does the nurse understand that a score of 9 indicates?
- A. The newborn will require resuscitation.
- B. The newborn may have physical disabilities.
- C. The newborn will have above average intelligence.
- D. The newborn is in stable condition.
Correct Answer: D
Rationale: Apgar scoring evaluates the infant's need for resuscitation. A score of 9 indicates that the newborn is stable.
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What marks the end of the third stage of labor?
- A. Full cervical dilation
- B. Expulsion of the placenta and membranes
- C. Birth of the infant
- D. Engagement of the head
Correct Answer: B
Rationale: The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.
The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?
- A. Fetal distress
- B. Fetal maturity
- C. Intact gastrointestinal tract
- D. Dehydration in the mother
Correct Answer: A
Rationale: Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.
What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push?
- A. At the beginning of a contraction, hold your breath and push for 10 seconds.'
- B. Take a deep breath and push between contractions.'
- C. Begin pushing when a contraction starts and continue for the duration of the contraction.'
- D. At the beginning of a contraction, take two deep breaths and push with the second exhalation.'
Correct Answer: D
Rationale: When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.
What is the nurse's most informative response?
- A. When you feel increased fetal movement
- B. When contractions are 10 minutes apart
- C. When membranes have ruptured
- D. When abdominal or groin discomfort occurs
Correct Answer: C
Rationale: Ruptured membranes are an indication that the woman should go to the hospital or birthing center.