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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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.
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.
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, meaning the baby's back is on the left side of the mother's spine and facing towards her back. This position is common during the early stages of labor. Choice A is incorrect as it describes a different position, choice B is incorrect as it refers to a different quadrant, and choice D is incorrect as it describes a location in the abdomen, not the pelvis.
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 (usually the biparietal diameter of the fetal head) passes through the pelvic inlet. This marks the beginning of the descent of the fetal head into the pelvis in preparation for birth. Extension (A) refers to the movement of the fetal head as it passes through the birth canal. Internal rotation (C) is the movement of the fetal head to align with the maternal pelvis. External rotation (D) occurs as the fetal head exits the birth canal.
A woman who is 39 weeks pregnant presents to the labor and delivery unit stating that she thinks she is in labor. Her contractions are irregular at 7 to 10 minutes apart. Which sign is definitive for true labor?
- A. Pain decreases when walking.
- B. Cervical dilation is occurring.
- C. The fetal membranes rupture.
- D. The fetal head is at –1 station.
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation is occurring. During true labor, the cervix begins to dilate and efface in preparation for childbirth. This process is a definitive sign of active labor. In contrast, the other choices are not definitive signs of true labor. Choice A is incorrect because pain decreasing when walking is not a specific indicator of true labor. Choice C, the fetal membranes rupturing, indicates the beginning of labor but is not the definitive sign. Choice D, the fetal head at –1 station, signifies the descent of the baby into the pelvis but does not confirm active labor.