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On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?
- A. Perform a vaginal exam to denote progress.
- B. Notify the health care provider.
- C. Initiate parenteral therapy.
- D. Apply oxygen via nasal cannula at 8 L/minut
Correct Answer: B
Rationale: The correct answer is B: Notify the health care provider. This is the priority intervention because a transverse lie is a malpresentation that can lead to complications during labor and delivery. The healthcare provider needs to be informed immediately to determine the best course of action, which may include attempting to manually rotate the baby or preparing for a cesarean section. Performing a vaginal exam (A) can be dangerous and should be avoided in cases of transverse lie. Initiating parenteral therapy (C) and applying oxygen (D) are not priorities in this situation as addressing the malpresentation is more urgent.
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A patient who is 8 cm dilated develops circumoral numbness and dizziness. What is the nurse’s priority intervention?
- A. Call the health care provider immediately.
- B. Increase intravenous fluid, as these are signs of hypovolemia.
- C. Have the patient slow down her breathing.
- D. Have her start pushing, as these are signs of the beginning of the second stage.
Correct Answer: C
Rationale: The correct answer is C: Have the patient slow down her breathing. Circumoral numbness and dizziness are signs of hyperventilation, which can occur due to rapid breathing during labor. Slowing down the patient's breathing helps prevent respiratory alkalosis and promotes proper oxygenation for both the mother and the baby. Calling the health care provider immediately (A) may cause a delay in addressing the immediate issue. Increasing IV fluids (B) may not address the root cause of the symptoms. Having her start pushing (D) prematurely can be harmful if she is not fully dilated.
Arrange the seven cardinal movements of labor, in order.
- A. Descent
- B. Expulsion
- C. Extension
- D. External rotation
Correct Answer: A
Rationale: The correct order of the seven cardinal movements of labor is: Descent, Flexion, Internal Rotation, Extension, Restitution, External Rotation, and Expulsion. Descent is the first cardinal movement, as the baby moves down the birth canal. Flexion follows to allow the baby's head to pass through the pelvis. Internal Rotation, Extension, and Restitution then occur to facilitate the baby's shoulders and body turning in alignment with the mother's pelvis. External Rotation follows to help the shoulders rotate to the correct position for delivery. Finally, Expulsion is when the baby is born. This sequence ensures a smooth and safe delivery. The other choices are incorrect as they are not part of the specific sequence of cardinal movements during labor.
Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?
- A. Station
- B. Flexion
- C. Descent
- D. Engagement
Correct Answer: B
Rationale: Flexion is the correct answer. During labor, fetal head flexion allows the smallest anterior-posterior diameter of the head to enter the pelvis first, reducing the risk of cephalopelvic disproportion. Station refers to the level of the presenting part in the maternal pelvis, not the head orientation. Descent is the downward movement of the fetus in the birth canal, not related to head position. Engagement occurs when the widest part of the presenting part reaches the level of the maternal ischial spines, not specifically related to the orientation of the fetal head.
To determine if the patient is in true labor, the nurse would assess for changes in
- A. cervical dilation.
- B. amount of bloody show.
- C. fetal position and station.
- D. pattern of uterine contractions.
Correct Answer: D
Rationale: The correct answer is D: pattern of uterine contractions. This is because the pattern of contractions is a key indicator of true labor. True labor contractions are regular, increasing in frequency, duration, and intensity. Assessing the pattern helps differentiate true labor from false labor.
A: Cervical dilation is important but may not necessarily indicate true labor as it can occur in false labor as well.
B: The amount of bloody show is a sign of cervical changes, but it alone does not confirm true labor.
C: Fetal position and station are important for labor progress but do not definitively confirm true labor.
In summary, assessing the pattern of uterine contractions is crucial in determining true labor as it provides direct insight into the progression and intensity of contractions, distinguishing it from false labor.
The nurse midwife caring for a multiparous client who is 5 cm dilated requests intermittent auscultation (IA) of the fetal heart rate. The woman’s history reveals no risk factors. How often should IA be performed in this patient?
- A. Every 15 minutes
- B. Every 5 minutes
- C. Every 20 minutes
- D. Every 30 minutes
Correct Answer: A
Rationale: The correct answer is A: Every 15 minutes. This frequency is recommended for a low-risk multiparous client in active labor without risk factors. Intermittent auscultation every 15 minutes allows for adequate monitoring of fetal well-being while also promoting maternal autonomy and mobility. Choices B, C, and D are incorrect because they are either too frequent or too infrequent for a low-risk client in active labor. Every 5 minutes (B) may be excessive and disrupt the labor process, every 20 minutes (C) may not provide sufficient monitoring, and every 30 minutes (D) may not detect changes in fetal status promptly.