Nokea
The nurse is caring for a patient during the first stage of labor. What is an abnormal finding?
- A. patient moaning with contractions
- B. contractions 3 minutes apart lasting 60 seconds
- C. blood pressure 142/88
- D. respiratory rate 22
Correct Answer: C
Rationale: The correct answer is C because a blood pressure of 142/88 is considered abnormal during the first stage of labor. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate medical attention.
A: Patient moaning with contractions is a common response to pain during labor and not necessarily abnormal.
B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor.
D: Respiratory rate of 22 is within the normal range and not indicative of any abnormalities during labor.
In summary, the abnormal finding in this scenario is the elevated blood pressure, which can be a sign of a serious condition like preeclampsia.
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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 the most appropriate nursing action because the patient is already in active labor (5 cm dilated), experiencing regular contractions, and has mild pain. Encouraging position changes can help progress labor by promoting optimal fetal positioning and descent, relieving pressure on the cervix, and enhancing uterine contractions. This can potentially shorten labor duration and reduce the risk of complications. Administering IV pain medicine (choice A) is not necessary at this stage as the pain is mild. Preparing for epidural anesthesia (choice C) is premature for mild pain and can slow down labor. Preparing for a cesarean section delivery (choice D) is not indicated at this point as the patient is progressing in labor.
A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
- A. The biparietal diameter of the fetal head is at the level of the ischial spines.
- B. The biparietal diameter of the fetal head is at –2 station.
- C. The fetal head is well flexed.
- D. The fetal head is unable to pass under the pubic arch.
Correct Answer: A
Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.
A laboring patient states to the nurse, "I have to push!” What is the next nursing action?
- A. Contact the health care provider.
- B. Examine the patient’s cervix for dilation.
- C. Review with her how to bear down with contractions.
- D. Ask her partner to support her head with each push.
Correct Answer: B
Rationale: The correct answer is B: Examine the patient’s cervix for dilation. This is the next nursing action because assessing cervical dilation is crucial in determining the progress of labor and if the patient is ready to push effectively. Contacting the health care provider (A) may cause unnecessary delays. Reviewing how to bear down with contractions (C) should be done after confirming cervical dilation. Asking her partner to support her head (D) is not the immediate priority in this situation.
The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
- A. Powers
- B. Passage
- C. Position
- D. Passenger
Correct Answer: A
Rationale: The correct answer is A: Powers. The four Ps of childbirth are Powers, Passage, Passenger, and Psyche. Powers refer to the contractions of the uterus and the pushing efforts of the mother during labor. Passage involves the birth canal through which the baby passes. Passenger refers to the fetus and its position during labor. Psyche relates to the psychological aspects of labor. In this case, Powers directly interact during childbirth by facilitating the progress of labor. Passage, Position, and Passenger are important factors as well, but they do not directly interact during childbirth like Powers do.
If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the
- A. head is in the right posterior quadrant of the pelvis.
- B. head is in the left anterior quadrant of the pelvis.
- C. buttocks are in the left posterior quadrant of the pelvis.
- D. buttocks are in the right upper quadrant of the abdomen.
Correct Answer: C
Rationale: The correct answer is C because LSP stands for Left Sacrum Posterior, meaning the baby's back is on the left side of the mother's spine and facing towards her back. This position is common during the early stages of labor. Choice A is incorrect as it describes a different position, choice B is incorrect as it refers to a different quadrant, and choice D is incorrect as it describes a location in the abdomen, not the pelvis.