Nokea
The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
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What signs and symptoms would lead the nurse to suspect false (prodromal) labor?
- A. Leaking of vaginal fluid
- B. Contractions intensify with ambulation
- C. Pink spotting
- D. Painless tightening of abdominal muscles
- E. Cervix thick and not effaced
Correct Answer: D,E
Rationale: Painless tightening of abdominal muscles (Braxton Hicks contractions) and a cervix that is thick and not effaced indicate false (prodromal) labor.
While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse's initial action?
- A. Stop the oxytocin infusion.
- B. Increase the intravenous flow rate.
- C. Reposition the woman on her side.
- D. Start oxygen via nasal cannula.
Correct Answer: C
Rationale: Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.
The nurse knows that what indicates the beginning of true labor?
- A. Contractions that are relieved by walking
- B. Discomfort in the abdomen and groin
- C. A decrease in vaginal discharge
- D. Regular contractions becoming more frequent and intense
Correct Answer: D
Rationale: In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.
What is the nurse's most informative response?
- A. When you feel increased fetal movement
- B. When contractions are 10 minutes apart
- C. When membranes have ruptured
- D. When abdominal or groin discomfort occurs
Correct Answer: C
Rationale: Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. What is this presentation?
- A. Vertex
- B. Military
- C. Brow
- D. Face
Correct Answer: A
Rationale: In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.