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How can a nurse support the patient during the fourth stage of labor?
- A. Support pushing efforts with feedback on how much progress is being made
- B. Ensure epidural anesthesia is adequate for pain control, reposition frequently, provide dietary intake per provider's order.
- C. Assess for any bleeding or amniotic fluid presence in the vaginal discharge
- D. Provide rest, space, and time for bonding between assessments, support for feeding
preferences, diligent monitoring for complications, pain management.
Correct Answer: D
Rationale: During the fourth stage of labor, it is important for the nurse to provide a supportive and nurturing environment for the mother and baby. This stage occurs immediately after the baby is born and lasts for about 2 hours. The mother may be exhausted from the physical effort of labor and delivery, so providing rest, space, and time for bonding between assessments is crucial. The nurse should also support the mother's feeding preferences, whether it is breastfeeding or formula feeding. Diligent monitoring for complications, such as postpartum hemorrhage or infection, is essential during this stage. Additionally, providing adequate pain management for any discomfort the mother may be experiencing is important.
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A patient asks the nurse how she can tell if labor is real. Which information should the nurse provide to this patient? (Select all that apply.)
- A. In true labor, the cervix begins to dilate
- B. In true labor, the contractions are felt in the abdomen and groin.
- C. In true labor, contractions often resemble menstrual cramps during early labor.
- D. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.
Correct Answer: A
Rationale: A. In true labor, the cervix begins to dilate: One of the key signs of true labor is that the cervix starts to dilate (open up) as the body prepares for childbirth. If a woman is experiencing real labor, her cervix will gradually start to open up to allow the baby to pass through the birth canal.
While attending the delivery of a patient with GODM, the nurse notices the retraction of the fetal head onto the perineum. What is the nurse’s next best action?
- A. Apply fundal pressure
- B. Assist the woman to left lateral position
- C. Flex the mother to left lateral position
- D. Assist the woman to hands-and-knees position
Correct Answer: D
Rationale: The retraction of the fetal head onto the perineum during labor can be indicative of shoulder dystocia or other obstructive complications, requiring immediate action. The best response is to assist the mother into hands-and-knees position, which can relieve pressure on the perineum and help with fetal descent.
Which clinical finding should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)
- A. A gush of blood appears.
- B. The uterus rises upward in the abdomen.
- C. The fundus descends below the umbilicus.
- D. The cord descends further from the vagin
Correct Answer: C
Rationale: A. A gush of blood appears: This clinical finding is indicative of the placenta detaching from the uterine wall and the subsequent expulsion. The sudden release of a significant amount of blood is expected as the placenta separates.
The nurse hears the laboring patient making grunting noises. How will the nurse determine if the person is in the active second stage of labor?
- A. Assess for rupture of membranes.
- B. Assess for bloody show.
- C. Assess for dilation of the cervix.
- D. Assess for stool.
Correct Answer: C
Rationale: In the active second stage of labor, the cervix is fully dilated to 10 centimeters. Grunting noises can be a sign of the transition to the pushing stage, which occurs in the active second stage of labor. Therefore, assessing for dilation of the cervix is crucial to determine if the laboring person is in the active second stage of labor.
An increase in urinary frequency and leg cramps after the 36th week of pregnancy are an indication of
- A. lightening.
- B. breech presentation.
- C. urinary tract infection.
- D. onset of Braxton-Hicks contractions.
Correct Answer: A
Rationale: An increase in urinary frequency and leg cramps after the 36th week of pregnancy are common signs of "lightening." Lightening refers to the descent of the baby into the pelvis in preparation for labor. This shift in position can put pressure on the bladder, leading to increased urinary frequency. Additionally, the pressure on nerves and blood vessels in the pelvis can cause leg cramps. These symptoms are typically experienced in the final weeks of pregnancy and are considered normal signs that the body is preparing for labor.