Nokea
The nurse hears the laboring patient making grunting noises. How will the nurse determine if the person is in the active second stage of labor?
- A. Assess for rupture of membranes.
- B. Assess for bloody show.
- C. Assess for dilation of the cervix.
- D. Assess for stool.
Correct Answer: C
Rationale: In the active second stage of labor, the cervix is fully dilated to 10 centimeters. Grunting noises can be a sign of the transition to the pushing stage, which occurs in the active second stage of labor. Therefore, assessing for dilation of the cervix is crucial to determine if the laboring person is in the active second stage of labor.
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Uncontrolled maternal hyperventilation during labor results in
- A. metabolic acidosis.
- B. metabolic alkalosis.
- C. respiratory acidosis.
- D. respiratory alkalosis.
Correct Answer: D
Rationale: Uncontrolled maternal hyperventilation during labor leads to excessive elimination of carbon dioxide, causing a decrease in the partial pressure of arterial carbon dioxide (PaCO2). This results in respiratory alkalosis, as the pH of the blood increases due to a decrease in PaCO2. Metabolic acidosis (Option A) would be associated with conditions such as lactic acidosis, while metabolic alkalosis (Option B) would involve excessive loss of acid or gain of base, but in this case, the primary effect is on the respiratory system. Respiratory acidosis (Option C) would be characterized by an increase in PaCO2 leading to a decrease in pH, which is the opposite of what occurs in maternal hyperventilation.
The nurse is assessing the duration of a patient’s labor contractions. Which method does the nurse implement to assess the duration of labor contractions?
- A. Assess the strongest intensity of each contraction.
- B. Assess uterine relaxation between two contractions.
- C. Assess from the beginning to the end of each contraction.
- D. Assess from the beginning of one contraction to the beginning of the next.
Correct Answer: C
Rationale: The nurse implements method C, which involves assessing the duration of contractions from the beginning to the end of each contraction. Duration refers to how long each contraction lasts from the start of the tightening sensation until it subsides. This assessment helps the nurse monitor the progress of labor, determine the effectiveness of contractions in dilating the cervix, and identify any potential issues such as prolonged or insufficient contractions that may affect labor progression. Assessing the duration of contractions is a key component of monitoring the labor process and ensuring safe delivery for both the mother and the baby.
A patient admitted to the labor unit asks the nurse to discuss the episiotomy procedure with her. Which is true regarding episiotomy?
- A. An episiotomy is required for all vaginal births.
- B. A midline episiotomy is associated with more third- and fourth-degree lacerations.
- C. A mediolateral episiotomy is easier to repair than a medial episiotomy.
- D. A midline episiotomy is associated with more blood loss.
Correct Answer: B
Rationale: A midline episiotomy is not required for all vaginal births, but it is associated with more third- and fourth-degree lacerations.
Uncontrolled maternal hyperventilation during labor results in
- A. metabolic acidosis.
- B. metabolic alkalosis.
- C. respiratory acidosis.
- D. respiratory alkalosis.
Correct Answer: D
Rationale: Uncontrolled maternal hyperventilation during labor leads to excessive elimination of carbon dioxide, causing a decrease in the partial pressure of arterial carbon dioxide (PaCO2). This results in respiratory alkalosis, as the pH of the blood increases due to a decrease in PaCO2. Metabolic acidosis (Option A) would be associated with conditions such as lactic acidosis, while metabolic alkalosis (Option B) would involve excessive loss of acid or gain of base, but in this case, the primary effect is on the respiratory system. Respiratory acidosis (Option C) would be characterized by an increase in PaCO2 leading to a decrease in pH, which is the opposite of what occurs in maternal hyperventilation.
How does becoming a parent cause the birthing person to feel?
- A. overwhelming feelings of joy or a sense of euphoria
- B. a wide variety of emotions specific to each person's experience
- C. overwhelming fear or sadness at the loss of their previous life
- D. exhausted with little interest the newborn
Correct Answer: B
Rationale: Becoming a parent can trigger a wide range of emotions that can vary from person to person. While feelings of joy and euphoria are commonly experienced, it is important to acknowledge that parenthood also brings about challenges, uncertainties, fears, and even feelings of loss or sadness. Each individual's background, personal experiences, support system, and circumstances play a significant role in shaping how they feel when they become a parent. It is normal for birthing persons to navigate through a mix of emotions as they adjust to their new role and responsibilities. Therefore, option B is the most appropriate choice as it recognizes the diverse emotional responses that can accompany the experience of becoming a parent.