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The nurse is caring for a gravida 5, para 4 who has been 5 centimeters dilated for 2 hours. The uterine contractions are every 5 minutes and mild to palpation. Which is the most appropriate nursing action?
- A. Administer ordered IV pain medicine
- B. Assist the patient with frequent position changes
- C. Prepare patient for epidural anesthesia
- D. Prepare patient for a cesarean section delivery
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with frequent position changes. This is because the patient is already 5cm dilated, indicating active labor. Position changes can help progress labor by promoting fetal descent and rotation. Administering pain medication (A) may not be necessary at this point as contractions are mild. Epidural anesthesia (C) may be considered later if requested by the patient. Cesarean section (D) is not indicated at this stage unless there are specific complications.
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How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?
- A. Invite the family to come in and see the newborn.
- B. Take the lead from the parents regarding interruption of the bonding.
- C. Ask multiple questions about taking pictures of the newborn.
- D. Take the newborn to the nursery to encourage the parents to rest.
Correct Answer: B
Rationale: The correct answer is B. In the fourth stage of labor, the nurse should respect the rapid psychologic changes by taking the lead from the parents regarding interruption of bonding. This is important because it allows the parents to establish a strong bond with their newborn without feeling pressured or rushed. By following the parents' cues, the nurse can support their emotional needs and facilitate a positive bonding experience.
Choices A, C, and D are incorrect because they do not prioritize the parents' emotional needs and may disrupt the bonding process. Inviting the family to see the newborn (Choice A) may add stress to the situation. Asking multiple questions about taking pictures (Choice C) may be intrusive. Taking the newborn to the nursery (Choice D) may interfere with the bonding process and discourage parental involvement.
A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
- A. A nitrazine test is the most conclusive test.
- B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.
- C. Ferning is more conclusive than nitrazine paper testing.
- D. Note if there is fluid leaking from the perineal area.
Correct Answer: A
Rationale: The correct answer is A. The nurse should perform a nitrazine test to determine if the fluid leaking is amniotic fluid. Here's the rationale:
1. Nitrazine test is specifically designed to differentiate amniotic fluid from urine.
2. Amniotic fluid is alkaline, causing the nitrazine paper to turn blue when it comes into contact with it.
3. Urine, on the other hand, does not change the color of the nitrazine paper.
4. This test is quick, easy to perform, and provides a conclusive result in differentiating amniotic fluid from other fluids.
In summary:
- Choice B incorrectly describes the color change mechanism of nitrazine paper.
- Choice C refers to ferning, which is not as conclusive as the nitrazine test.
- Choice D does not provide a definitive method for determining if the leaking fluid is amniotic fluid.
A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?
- A. Perform a vaginal examination to determine cervical dilation
- B. Assist the health care provider to perform artificial rupture of the membranes
- C. Initiate external fetal monitoring
- D. Encourage patient to ambulate to intensify labor
Correct Answer: C
Rationale: The correct answer is C: Initiate external fetal monitoring. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.
A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
- A. more rapid labor.
- B. a high risk of infection.
- C. maternal perineal traum
- D. umbilical cord compression.
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet are positioned to come out first, which can lead to potential umbilical cord compression during labor. This compression can compromise fetal oxygenation and circulation, posing a serious risk to the baby's well-being. The other choices are incorrect because a breech presentation is not typically associated with more rapid labor (choice A), a high risk of infection (choice B), or maternal perineal trauma (choice C). It is important for healthcare providers to be vigilant in monitoring for signs of umbilical cord compression in cases of breech presentation to ensure the safety of both the mother and baby.
Which physiologic event is the key indicator of the commencement of true labor?
- A. Bloody show
- B. Cervical dilation and effacement
- C. Fetal descent into the pelvic inlet
- D. Uterine contractions every 7 minutes
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation and effacement. This is the key indicator of true labor as it signifies the physiological changes needed for the cervix to open and thin out, allowing the baby to pass through the birth canal. Bloody show (A) can be present in early labor but is not a definitive sign. Fetal descent (C) and regular uterine contractions (D) are important, but cervical changes are the most reliable indicator of true labor initiation.