Nokea
During the third stage of labor, what may the birthing person experience?
- A. expulsion of their fetus with vaginal bleeding
- B. cramping, gush of fresh vaginal bleeding, lengthening of the umbilical cord
- C. frequent episodes of dyspnea
- D. increased blood pressure and pain due to expulsive efforts
Correct Answer: B
Rationale: During the third stage of labor, the correct answer is B because it describes the typical experiences of the birthing person during this stage. Cramping signifies uterine contractions, a gush of fresh vaginal bleeding indicates the delivery of the placenta, and lengthening of the umbilical cord indicates separation from the placenta. The other options are incorrect as they do not align with the physiological processes of the third stage of labor. A is incorrect as the fetus is delivered in the second stage, not the third. C is incorrect as dyspnea (difficulty breathing) is not a common symptom during the third stage. D is incorrect as increased blood pressure and pain are not typical experiences during this stage.
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The nurse is caring for a laboring patient with multiple family members in the room. How can the nurse address this situation?
- A. Educate the family that the pain the laboring person is experiencing is normal.
- B. Ask them all to leave the room.
- C. Explain that if the laboring person got an epidural, she would be more comfortable
- D. Assume the laboring person wants the family in the room
Correct Answer: B
Rationale: The correct answer is B, asking all family members to leave the room. This is important to provide privacy, reduce distractions, and maintain the laboring person's comfort and focus. Educating the family on pain normalcy (A) is secondary to the laboring person's immediate needs. Suggesting an epidural (C) without the laboring person's consent is inappropriate. Assuming the laboring person wants the family in the room (D) disregards the individual's preferences and comfort.
A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?
- A. Perform a vaginal examination to determine cervical dilation
- B. Assist the health care provider to perform artificial rupture of the membranes
- C. Initiate external fetal monitoring
- D. Encourage patient to ambulate to intensify labor
Correct Answer: C
Rationale: The correct answer is C: Initiate external fetal monitoring. The nurse should initiate external fetal monitoring to assess the fetus's heart rate and uterine contractions, given the patient's history of placenta previa and vaginal bleeding. This helps to monitor the well-being of the fetus and detect any signs of distress. Performing a vaginal examination (Choice A) may aggravate the placenta previa and increase the risk of bleeding. Artificial rupture of membranes (Choice B) is contraindicated in cases of placenta previa due to the risk of increased bleeding. Encouraging ambulation (Choice D) is not advisable in this situation as it may also worsen bleeding.
A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
- A. The biparietal diameter of the fetal head is at the level of the ischial spines.
- B. The biparietal diameter of the fetal head is at –2 station.
- C. The fetal head is well flexed.
- D. The fetal head is unable to pass under the pubic arch.
Correct Answer: A
Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.
Which is the cervical exam that most indicates the use of misoprostol?
- A. 1 cm dilated, 20% effaced, -3 station, firm and posterior
- B. 3-4 cm dilated, 50% effaced, -2 station, firm and midposition
- C. 5 cm dilated, 80% effaced, 0 station, soft and midposition
- D. 6 cm dilated, 100% effaced, +1 station, soft and anterior
Correct Answer: A
Rationale: Step 1: Misoprostol is a medication used for cervical ripening and induction of labor.
Step 2: The characteristics of the cervix that indicate the need for misoprostol are early in the dilation process (1 cm dilated), minimally effaced (20%), high station (-3), and firm and posterior position.
Step 3: Choice A best aligns with these characteristics, making it the correct answer.
Step 4: Choices B, C, and D are more advanced in dilation, effacement, station, and cervical position which do not indicate the need for misoprostol.
The nurse is caring for a gravida 5, para 4 who has been 5 centimeters dilated for 2 hours. The uterine contractions are every 5 minutes and mild to palpation. Which is the most appropriate nursing action?
- A. Administer ordered IV pain medicine
- B. Assist the patient with frequent position changes
- C. Prepare patient for epidural anesthesia
- D. Prepare patient for a cesarean section delivery
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with frequent position changes. This is because the patient is already 5cm dilated, indicating active labor. Position changes can help progress labor by promoting fetal descent and rotation. Administering pain medication (A) may not be necessary at this point as contractions are mild. Epidural anesthesia (C) may be considered later if requested by the patient. Cesarean section (D) is not indicated at this stage unless there are specific complications.