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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.
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The nurse is trying to differentiate true labor from false labor. Which of the following is correct regarding true labor?
- A. Discomfort of the contraction is in the fundus.
- B. Contractions do not follow a pattern.
- C. Contractions get stronger with ambulation.
- D. Contractions may stop with ambulation.
Correct Answer: C
Rationale: Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions.
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.
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.
When observing the fetal heart monitor the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
- A. Early deceleration due to head compression
- B. That the fetus is in acute distress
- C. Variable decelerations due to cord compression
- D. That these are late decelerations
Correct Answer: A
Rationale: This indicates early decelerations because of head compression.
Why is the size and shape of the true pelvis more important than that of the false pelvis?
- A. The fetal head must be able to pass through the true pelvis.
- B. The true pelvis are the mother's measurements.
- C. The size of the false pelvis can change.
- D. The size of the true pelvis needs to be larger.
Correct Answer: A
Rationale: The size and shape of the true pelvis is more important than the false pelvis because the fetal head must be able to pass through for vaginal delivery to occur.