Nokea
During labor the patient screams at her husband to get out of her sight. What would be the most appropriate action for the nurse?
- A. Ask the husband to leave the room.
- B. Assure the husband that such behavior is normal.
- C. Remind the patient that the husband wants to help.
- D. Change the patient's position.
Correct Answer: B
Rationale: During labor the patient frequently becomes angry and outspoken. It is a normal occurrence, but the husband needs to be reassured that such behavior is normal.
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A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
- A. There is no dilation.
- B. The contractions are in the fundus.
- C. The cervix has softened and effaced.
- D. The contractions are irregular.
Correct Answer: C
Rationale: One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic.
A mother has entered the second stage of labor. When does the second stage of labor end?
- A. When the mother begins to push
- B. When the baby's head crowns
- C. With delivery of the baby
- D. With delivery of the placenta
Correct Answer: C
Rationale: The second stage of labor begins with complete dilation and ends with the birth of the baby.
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.
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.
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
- A. Cool fluids to drink
- B. A backrub in the sacral area
- C. Assisting to lie in a supine position
- D. Decreasing illumination in the room
Correct Answer: B
Rationale: Backache in the sacral area is a common complaint during the first stage of labor. The keyword is "comfort" in the question. Providing a backrub is providing comfort to the laboring patient.