Nokea
How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?
- A. Invite the family to come in and see the newborn.
- B. Take the lead from the parents regarding interruption of the bonding.
- C. Ask multiple questions about taking pictures of the newborn.
- D. Take the newborn to the nursery to encourage the parents to rest.
Correct Answer: B
Rationale: The correct answer is B because in the fourth stage of labor, immediate postpartum bonding between parents and newborn is crucial. The nurse should respect the rapid psychologic changes by taking cues from the parents on how they want this bonding experience to unfold. This approach ensures that the parents are supported in establishing a strong emotional bond with their newborn, promoting a positive postpartum experience.
Choice A is incorrect because inviting the family in may not align with the parents' wishes for privacy during this intimate moment. Choice C is incorrect as asking multiple questions about taking pictures may be intrusive and disrupt the bonding process. Choice D is incorrect as separating the newborn from the parents can hinder bonding and may not align with current best practices in postpartum care.
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What is a direct influence on cervical dilation? Select all that apply.
- A. positioning of the pregnant person
- B. strength of uterine contractions
- C. length of time since ROM
- D. fetal presentation
Correct Answer: A
Rationale: The correct answer is A: positioning of the pregnant person. The position of the pregnant person can directly influence cervical dilation by affecting the alignment of the uterus and baby, allowing for optimal pressure on the cervix. Proper positioning can facilitate the descent of the baby's head onto the cervix, promoting dilation.
Summary of why other choices are incorrect:
B: The strength of uterine contractions indirectly influences cervical dilation by aiding in the effacement and descent of the baby, but it does not directly impact dilation.
C: The length of time since ROM (rupture of membranes) can affect the risk of infection but does not directly influence cervical dilation.
D: Fetal presentation refers to the position of the baby in the uterus and can affect labor progress, but it does not directly impact cervical dilation.
The nurse is caring for a patient during the first stage of labor. What is an abnormal finding?
- A. patient moaning with contractions
- B. contractions 3 minutes apart lasting 60 seconds
- C. blood pressure 142/88
- D. respiratory rate 22
Correct Answer: C
Rationale: The correct answer is C because a blood pressure of 142/88 is considered high and abnormal during the first stage of labor. This could indicate hypertension, which can have serious implications for both the mother and the baby. High blood pressure can lead to complications such as preeclampsia.
A, B, and D are incorrect because:
A: Patient moaning with contractions is a common response to labor pains and does not necessarily indicate an abnormal finding.
B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor.
D: A respiratory rate of 22 is also within the normal range and is not indicative of any abnormal findings during the first stage of labor.
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 because having multiple family members in the room during labor can be overwhelming and hinder the progress of labor. It is important for the laboring person to have privacy, focus, and reduce stress for a smoother labor experience. Asking the family members to leave the room ensures a calm and supportive environment for the laboring person.
Incorrect Choices:
A: Educating the family about pain normalcy is helpful, but privacy and focus are more crucial during labor.
C: Mentioning epidural may not be appropriate as it is the laboring person's decision and may not be the best option for everyone.
D: Assuming the laboring person wants family in the room without considering their preference may not be the best approach for their comfort and progress in labor.
A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?
- A. Notify the operating team of emergent cesarean delivery
- B. Assist the patient to left lateral position
- C. Apply O2 at 10-12 L/min per nonrebreather
- D. Administer an IV fluid bolus
Correct Answer: A
Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. In this scenario, the presence of bloody amniotic fluid and fetal heart rate decelerations to the 50s indicate potential fetal distress. Given the critical nature of this situation, an emergent cesarean delivery should be considered to expedite delivery and prevent further compromise to the fetus. This decision is based on the principle of prioritizing fetal well-being in situations of acute distress. Options B, C, and D do not address the immediate need for prompt intervention to ensure the safety of the fetus in distress.
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. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.