Nokea
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
- A. Cool fluids to drink
- B. A backrub in the sacral area
- C. Assisting to lie in a supine position
- D. Decreasing illumination in the room
Correct Answer: B
Rationale: Backache in the sacral area is a common complaint during the first stage of labor. The keyword is "comfort" in the question. Providing a backrub is providing comfort to the laboring patient.
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A primigravida has a pelvis of the android type which usually means the delivery will be a ___.
Correct Answer: cesarean
Rationale: The narrow outlet of the android-type pelvis usually requires a cesarean delivery.
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take?
- A. Monitor intensity of contractions.
- B. Place the patient in the knee-chest position.
- C. Notify the charge nurse.
- D. Ask the patient to perform a Valsalva's maneuver.
Correct Answer: B
Rationale: The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse will need to be notified, and the contractions will need to be monitored. However, the priority is reducing the pressure on the prolapsed cord.
A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
- A. Correctly identifying abnormal FHR patterns and prescribing medication
- B. Correctly identifying abnormal FHR patterns and notifying the health care provider
- C. The nurse is not legally responsible for fetal monitoring
- D. Providing technical assessment to the monitor technicians
Correct Answer: B
Rationale: Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order.
A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center?
- A. The patient is a primigravida.
- B. The patient will be having a planned cesarean delivery.
- C. The mother has preeclampsia.
- D. The baby is a boy.
- E. The mother has no support system.
Correct Answer: B,C
Rationale: Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mother's support system would not be factors considered when determining risk for delivering in a birthing center.
A woman who is 38 weeks' pregnant tells the nurse that the baby has dropped and she is having urinary frequency again. What do these symptoms describe?
- A. Lightening
- B. Braxton-Hicks contractions
- C. Initiation of labor
- D. Engagement
Correct Answer: A
Rationale: The symptoms of lightening are a return of urinary frequency, and the patient is able to breathe more normally.