Nokea
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. In the case of a transverse lie, the fetus is positioned sideways in the uterus, which can lead to complications during labor. Notifying the health care provider is crucial as they will need to assess the situation and determine the appropriate course of action, such as attempting to manually rotate the fetus or preparing for a cesarean section if necessary. Performing a vaginal exam (choice A) may not be safe or effective in this situation. Initiating parenteral therapy (choice C) and applying oxygen (choice D) are not the priority interventions in the case of a transverse lie.
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A fetus is positioned in a longitudinal lie with its head in the fundus with both hips and knees flexed. Which presentation is this known as?
- A. Frank breech
- B. Complete breech
- C. Vertex
- D. Transverse
Correct Answer: B
Rationale: The correct answer is B: Complete breech. In this presentation, the fetus is positioned with hips and knees flexed, and the head is in the fundus. This is different from a Frank breech where the hips are flexed but the knees are extended. Vertex presentation refers to the head being down and Transverse presentation is when the fetus is lying horizontally. In this case, the description matches the characteristics of a complete breech presentation, making it the correct answer.
When does the active phase of labor begin according to ACOG?
- A. 6 cm
- B. 3 cm
- C. 5 cm
- D. 10 cm
Correct Answer: A
Rationale: The active phase of labor begins at 6 cm dilation according to ACOG guidelines. At this point, the cervix is significantly dilated, signaling the transition to active labor. This stage is crucial as it signifies the acceleration of labor progress and typically involves stronger contractions leading to efficient cervical dilation. Choices B, C, and D are incorrect as they do not align with the established criteria for the active phase of labor. Choice B (3 cm) is too early for active labor, choice C (5 cm) is close but not quite at the threshold for active labor, and choice D (10 cm) is actually the full dilation stage, not the beginning of active labor. Hence, choice A (6 cm) is the correct answer.
A 28-year-old gravida 1, para 0 patient who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet;
- A. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. Which questions should the nurse pose to the patient during this telephone triage? (Select all that apply.)
- B. Does she think that her membranes have ruptured?
- C. Is there any evidence of bloody show?
- D. Instruct the patient to keep monitoring her contraction pattern and call you back if they become more regular.
Correct Answer: A
Rationale: The correct answer is A because the patient's irregular contraction pattern and varying duration indicate early labor. By asking the patient about the contraction pattern, the nurse can assess the progression of labor and provide appropriate guidance. Choice B is incorrect because if the patient's membranes have ruptured, she would most likely feel a gush of fluid rather than just feeling wet. Choice C is incorrect as bloody show is not typically a reliable indicator of early labor. Choice D is incorrect as it does not address the need to assess the contraction pattern for progression of labor.
What anticipatory guidance should the nurse provide for new parents regarding sociologic changes?
- A. Explain that roles will not change at home
- B. Explain that stresses will be over now that the newborn is born.
- C. Tell the parents not to stress over household changes.
- D. Prepare them for possible strains on relationships.
Correct Answer: D
Rationale: The correct answer is D because it addresses the potential strains on relationships that can occur after the birth of a child. New parents often experience changes in their relationship dynamics due to increased responsibilities, sleep deprivation, and shifts in priorities. By preparing them for these possible strains, the nurse can help them navigate these challenges effectively.
A is incorrect because roles often do change at home with the arrival of a newborn. B is incorrect as stresses can actually increase after the baby is born. C is incorrect as it dismisses the importance of addressing household changes and potential stressors.
A 35-year-old gravida 1, para 0 is admitted to the labor and delivery unit. She reports intense rectal pressure. Which stage of labor is probable?
- A. First stage, latent
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: B
Rationale: The correct answer is B: Second stage. This stage of labor is characterized by full dilation of the cervix and ends with the delivery of the baby. The intense rectal pressure reported by the patient indicates that the baby is descending through the birth canal, which is a hallmark sign of the second stage. In contrast, the first stage, latent (choice A) is characterized by early labor contractions and cervical dilation up to 6 cm. The third stage (choice C) is the delivery of the placenta, and the fourth stage (choice D) is the immediate postpartum period. The key here is recognizing the specific symptom of intense rectal pressure, which aligns with the second stage of labor.