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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 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.
How can a nurse support the patient during the fourth stage of labor?
- A. Support pushing efforts with feedback on how much progress is being made
- B. Ensure epidural anesthesia is adequate for pain control, reposition frequently, provide dietary intake per provider's order.
- C. Assess for any bleeding or amniotic fluid presence in the vaginal discharge
- D. Provide rest, space, and time for bonding between assessments, support for feeding
preferences, diligent monitoring for complications, pain management.
Correct Answer: D
Rationale: During the fourth stage of labor, it is important for the nurse to provide a supportive and nurturing environment for the mother and baby. This stage occurs immediately after the baby is born and lasts for about 2 hours. The mother may be exhausted from the physical effort of labor and delivery, so providing rest, space, and time for bonding between assessments is crucial. The nurse should also support the mother's feeding preferences, whether it is breastfeeding or formula feeding. Diligent monitoring for complications, such as postpartum hemorrhage or infection, is essential during this stage. Additionally, providing adequate pain management for any discomfort the mother may be experiencing is important.
How can a nurse support the patient during the fourth stage of labor?
- A. Support pushing efforts with feedback on how much progress is being made
- B. Ensure epidural anesthesia is adequate for pain control, reposition frequently, provide dietary intake per provider's order.
- C. Assess for any bleeding or amniotic fluid presence in the vaginal discharge
- D. Provide rest, space, and time for bonding between assessments, support for feeding
preferences, diligent monitoring for complications, pain management.
Correct Answer: D
Rationale: During the fourth stage of labor, it is important for the nurse to provide a supportive and nurturing environment for the mother and baby. This stage occurs immediately after the baby is born and lasts for about 2 hours. The mother may be exhausted from the physical effort of labor and delivery, so providing rest, space, and time for bonding between assessments is crucial. The nurse should also support the mother's feeding preferences, whether it is breastfeeding or formula feeding. Diligent monitoring for complications, such as postpartum hemorrhage or infection, is essential during this stage. Additionally, providing adequate pain management for any discomfort the mother may be experiencing is important.
A fetus is in the occiput anterior position. During the cardinal movement of extension, which events are occurring? Select all that apply.
- A. The fetal head lines up with the pelvic outlet.
- B. The occiput passes under the symphysis pubis.
- C. The fetal head is engaged.
- D. The head is delivered.
Correct Answer: A
Rationale: During extension, the fetal head lines up with the pelvic outlet, and the occiput passes under the symphysis pubis.
The onset of labor is multifactorial. These reasons include which of the following? Select all that apply.
- A. Increase in progesterone
- B. Increase in estrogen
- C. Increase in human chorionic gonadotropin
- D. Aging of placenta
Correct Answer: B
Rationale: Increase in progesterone, estrogen, aging of placenta, and fetal hormones are the factors contributing to the onset of labor.