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. In the fourth stage of labor, the nurse should respect the rapid psychologic changes by taking the lead from the parents regarding interruption of bonding. This is important because it allows the parents to establish a strong bond with their newborn without feeling pressured or rushed. By following the parents' cues, the nurse can support their emotional needs and facilitate a positive bonding experience.
Choices A, C, and D are incorrect because they do not prioritize the parents' emotional needs and may disrupt the bonding process. Inviting the family to see the newborn (Choice A) may add stress to the situation. Asking multiple questions about taking pictures (Choice C) may be intrusive. Taking the newborn to the nursery (Choice D) may interfere with the bonding process and discourage parental involvement.
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Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
- A. Extension
- B. Engagement
- C. Internal rotation
- D. External rotation
Correct Answer: B
Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part passes through the pelvic inlet, indicating the descent of the fetal head into the pelvis. This is a crucial step in labor progress as it signifies the baby's readiness for birth.
A: Extension occurs during the second stage of labor when the baby's head passes through the birth canal.
C: Internal rotation is the movement of the baby's head within the pelvis to align with the maternal pelvis.
D: External rotation happens after the baby's head is delivered to allow for the shoulders to rotate for birth.
In summary, engagement is the correct answer as it specifically refers to the largest diameter of the fetal presenting part passing the pelvic inlet, setting the stage for the progression of labor.
If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the
- A. head is in the right posterior quadrant of the pelvis.
- B. head is in the left anterior quadrant of the pelvis.
- C. buttocks are in the left posterior quadrant of the pelvis.
- D. buttocks are in the right upper quadrant of the abdomen.
Correct Answer: C
Rationale: The correct answer is C because LSP stands for Left Sacrum Posterior, indicating the baby's buttocks are in the left posterior quadrant of the pelvis. In this position, the baby's head will typically be in the right anterior quadrant of the pelvis. Choice A is incorrect as it describes the head in the right posterior quadrant. Choice B is incorrect as it describes the head in the left anterior quadrant. Choice D is incorrect as it describes the buttocks in the right upper quadrant of the abdomen, which is not related to the fetal position LSP.
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 because the positioning of the pregnant person affects the alignment of the baby's head in the pelvis, directly influencing cervical dilation. Proper positioning helps the baby apply pressure to the cervix, promoting dilation. In contrast, the strength of uterine contractions (B) affects labor progress but not cervical dilation specifically. The length of time since ruptured membranes (C) may increase infection risk but does not directly impact dilation. Fetal presentation (D) affects the descent of the baby, not cervical dilation.
The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction?
- A. Little to no affect
- B. Increases as blood pressure decreases
- C. Diminishes as the spiral arteries are compressed
- D. Continues except when placental functions are reduced
Correct Answer: D
Rationale: The correct answer is D because maternal-fetal exchange of oxygen and waste products continues during uterine contractions unless placental functions are reduced. Contractions do not directly affect this exchange, so option A is incorrect. Option B is incorrect because blood pressure changes do not necessarily impact the exchange. Option C is incorrect because spiral arteries play a role in supplying blood to the placenta, but compression during contractions does not halt the exchange process.
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.