Nokea
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.
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A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
- A. Correctly identifying abnormal FHR patterns and prescribing medication
- B. Correctly identifying abnormal FHR patterns and notifying the health care provider
- C. The nurse is not legally responsible for fetal monitoring
- D. Providing technical assessment to the monitor technicians
Correct Answer: B
Rationale: Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order.
After the delivery of a newborn what is the priority action of the nurse?
- A. Place the newborn on the right side.
- B. Cover the cord stump.
- C. Dry the infant immediately.
- D. Suction nose and mouth.
Correct Answer: D
Rationale: To prevent aspiration of amniotic fluid, the baby should be suctioned, then quickly dried to prevent hypothermia.
A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center?
- A. The patient is a primigravida.
- B. The patient will be having a planned cesarean delivery.
- C. The mother has preeclampsia.
- D. The baby is a boy.
- E. The mother has no support system.
Correct Answer: B,C
Rationale: Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mother's support system would not be factors considered when determining risk for delivering in a birthing center.
The patient's membranes have just ruptured. What is the first priority of the nurse?
- A. Turn the patient on the left side.
- B. Perform a Nitrazine test.
- C. Check the fetal heart rate (FHR).
- D. Perform a vaginal examination.
Correct Answer: C
Rationale: The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby.
A primigravida patient is admitted to the labor and delivery unit. During initial assessment the baby is found to be engaged. Which statement is true?
- A. The narrowest diameter of the presenting part has reached the pelvic outlet.
- B. The descending part is being initiated through the midpelvis.
- C. The widest diameter of the presenting part crosses the pelvic inlet.
- D. The narrowest diameter of the presenting part is at the ischial spines.
Correct Answer: C
Rationale: Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet.