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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.
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A woman has chosen a trial of labor after cesarean. Which findings indicate the best understanding of the nurse’s teaching by the patient?
- A. "It is safer for me to be induced at 39 weeks so that my labor can be controlled and monitored carefully.”
- B. "I will need to arrive to the hospital the night before my induction so that my cervix can be ripened with prostaglandins.”
- C. "If I do not go into labor on my own, I will have to have a cesarean section since Pitocin is contraindicated for me.”
- D. "A balloon catheter may be used to manually ripen my cervix, if necessary”
Correct Answer: D
Rationale: The correct understanding is that cervical ripening may be necessary before induction, and a balloon catheter can be used for this purpose. This is part of the education provided to patients who opt for a trial of labor after cesarean.
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.
A 24-year-old G4 T1 A2 L1 presents to obstetric triage with complaints of contractions every 3 minutes, accompanied by bright red vaginal bleeding. The woman is 29 weeks gestation with a twin pregnancy. She has had three urinary tract infections during this pregnancy and is currently taking Microbid daily as prophylaxis. Her last baby was born via cesarean section for breech malpresentation. She denies any other significant medical history. What risk factors for placenta previa does this patient have? Select all that apply.
- A. Maternal age of 24
- B. Twin gestation
- C. Gestational age of 29 weeks
- D. Previous delivery by cesarean section
Correct Answer: D
Rationale: The patient's age, history of cesarean section, and twin gestation all contribute to an increased risk of placenta previa. The most significant risk factor here is the previous cesarean section, which can cause scarring and increase the likelihood of abnormal placental implantation.
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.
Which assessment finding indicates that cervical dilation and/or effacement has occurred?
- A. Onset of irregular contractions
- B. Cephalic presentation at 0 station
- C. Bloody mucus drainage from vagina
- D. Fetal heart tones (FHTs) present in the lower right quadrant
Correct Answer: C
Rationale: Bloody mucus drainage from the vagina, also known as "bloody show," is a common sign that indicates cervical dilation and/or effacement has occurred in anticipation of labor. This occurs as the mucus plug, which seals the cervix during pregnancy, is released as the cervix begins to soften, dilate, and efface in preparation for childbirth. This physical change in the cervix is a significant indicator that labor is approaching. The other options listed do not directly indicate cervical changes associated with labor progression like the presence of bloody mucus drainage does.