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The nurse is admitting a patient to the labor and delivery unit. While performing the initial assessment which assessment is the priority?
- A. The number of previous pregnancies
- B. When the baby is due
- C. When the patient last ate
- D. The timing of contractions
Correct Answer: D
Rationale: Assessment begins with timing the contractions on admission to form a database.
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A woman is admitted in active labor and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment?
- A. Position patient on her left side.
- B. Start oxygen per nasal cannula.
- C. Reassure the mother the rate is normal.
- D. Notify the health care provider at once.
Correct Answer: C
Rationale: The normal FHR is 120 to 160 beats/min. No interventions are required.
A mother is in early labor and asks the nurse how long the labor will last. The nurse explains that the first stage of labor lasts from the beginning of regular contractions until when?
- A. The cervix is completely effaced.
- B. The baby is in position.
- C. The cervix is fully dilated.
- D. The woman begins pushing.
Correct Answer: C
Rationale: The first stage of labor begins with regular contractions and ends with complete dilation of the cervix.
A mother has entered the second stage of labor. When does the second stage of labor end?
- A. When the mother begins to push
- B. When the baby's head crowns
- C. With delivery of the baby
- D. With delivery of the placenta
Correct Answer: C
Rationale: The second stage of labor begins with complete dilation and ends with the birth of the baby.
The nurse explains to the patient whose membranes ruptured an hour ago that delivery is usually accomplished in ___ to 24 hours postrupture.
Correct Answer: 18
Rationale: After the rupture of membranes, labor is usually accomplished in 18 to 24 hours.
How do Braxton-Hicks contractions differ from labor contractions?
- A. Last several minutes.
- B. Are always regular.
- C. Do not dilate the cervix.
- D. Are only mild.
Correct Answer: C
Rationale: Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can range from mild to moderate in severity, and increase in duration as the pregnancy progresses.