Nokea
The labor and delivery nurse is caring for a 27-year-old primigravida with the following vaginal exam: 2 to 3 cm dilated/70% effaced/-2 station. For the last 2 hours the FHR tracing has displayed a Category I tracing and uterine contractions that are every 2 minutes. The contractions are strong to palpation and the patient is now 3/70%/-2. Which is the nurse’s next best action?
- A. Encourage the patient to ambulate
- B. Request orders to initiate oxytocin
- C. Assist the patient to a warm bath
- D. Document the findings
Correct Answer: D
Rationale: The correct answer is D, documenting the findings. In this scenario, the patient is in active labor with regular strong contractions, cervical change, and a reassuring fetal heart rate tracing. The priority is to document these important clinical findings accurately for proper assessment and monitoring of progress. Encouraging ambulation (A) may not be safe due to the frequency and strength of contractions. Initiating oxytocin (B) is unnecessary as labor is progressing well on its own. Assisting the patient to a warm bath (C) may provide comfort but is not the most critical action at this time.
You may also like to solve these questions
During an oxytocin induction, which assessment finding is most concerning to the labor and delivery nurse?
- A. A uterine resting tone of 17 mm Hg
- B. A uterine resting tone of 30 mm Hg
- C. Contractions that are every 3 minutes and last 60 seconds
- D. Contractions that are every 5 minutes and last 60 seconds
Correct Answer: B
Rationale: The correct answer is B (A uterine resting tone of 30 mm Hg) because a high uterine resting tone indicates uterine hyperstimulation, which can lead to uterine rupture, fetal distress, and compromised blood flow to the placenta. A higher resting tone of 30 mm Hg is concerning compared to the normal range of 12-18 mm Hg.
Choice A (A uterine resting tone of 17 mm Hg) is within the normal range, so it is not as concerning as a higher resting tone.
Choices C (Contractions every 3 minutes lasting 60 seconds) and D (Contractions every 5 minutes lasting 60 seconds) describe the frequency and duration of contractions, which are important but are not as immediately concerning as a high uterine resting tone.
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.
Which explains why infants who are delivered via cesarean section before the start of labor have more difficulty transitioning to extrauterine life?
- A. The use of warm IV fluids precipitates hyperthermia.
- B. Regional anesthesia causes respiratory depression.
- C. The maternal left tilt position reduces placental blood flow.
- D. Residual amniotic fluid in the lungs makes spontaneous respirations difficult.
Correct Answer: D
Rationale: The correct answer is D because infants delivered via cesarean section before labor may not have had the opportunity to expel amniotic fluid from their lungs through the vaginal passage, leading to respiratory distress. This residual fluid can hinder the initiation of spontaneous respirations, causing difficulty in transitioning to extrauterine life. Choices A, B, and C are incorrect because hyperthermia from warm IV fluids, respiratory depression from regional anesthesia, and reduced placental blood flow from maternal position are not primary factors affecting the infant's ability to transition to extrauterine life in this scenario.
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.
The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
- A. Offer the patient a warm blanket.
- B. Place an ice pack on the perineum.
- C. Massage the uterus if it is boggy.
- D. Delay breastfeeding until the patient is reste
Correct Answer: A
Rationale: The correct answer is A: Offer the patient a warm blanket. In the fourth stage of labor, the mother experiences postpartum hemorrhage risk due to uterine atony. Keeping the patient warm helps prevent hypothermia, which can lead to increased bleeding. Ice packs (B) are not indicated as they can cause vasoconstriction and inhibit proper blood flow. Massaging the uterus (C) is appropriate in the third stage of labor to prevent hemorrhage but not in the fourth stage. Delaying breastfeeding (D) is incorrect as early breastfeeding promotes uterine contractions, reducing the risk of postpartum hemorrhage.