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 high and abnormal during the first stage of labor. This could indicate hypertension, which can have serious implications for both the mother and the baby. High blood pressure can lead to complications such as preeclampsia.
A, B, and D are incorrect because:
A: Patient moaning with contractions is a common response to labor pains and does not necessarily indicate an abnormal finding.
B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor.
D: A respiratory rate of 22 is also within the normal range and is not indicative of any abnormal findings during the first stage of labor.
You may also like to solve these questions
The nurse is explaining the physiology of uterine contractions to a group of nursing students. Which statement best explains the maternal-fetal exchange of oxygen and waste products during a contraction?
- A. Little to no affect
- B. Increases as blood pressure decreases
- C. Diminishes as the spiral arteries are compressed
- D. Continues except when placental functions are reduced
Correct Answer: D
Rationale: The correct answer is D because maternal-fetal exchange of oxygen and waste products continues during uterine contractions unless placental functions are reduced. Contractions do not directly affect this exchange, so option A is incorrect. Option B is incorrect because blood pressure changes do not necessarily impact the exchange. Option C is incorrect because spiral arteries play a role in supplying blood to the placenta, but compression during contractions does not halt the exchange process.
Which assessment finding would cause a concern for a patient who had delivered vaginally?
- A. Estimated blood loss (EBL) of 500 mL during the birth process
- B. White blood cell count of 28,000 mm3 postbirth
- C. Patient complains of fingers tingling
- D. Patient complains of thirst
Correct Answer: B
Rationale: The correct answer is B - White blood cell count of 28,000 mm3 postbirth. This finding indicates a possible infection or inflammation, which can be concerning after vaginal delivery. A high white blood cell count may suggest an ongoing infection that needs immediate attention.
A: Estimated blood loss of 500 mL is within normal range for vaginal delivery and is not a cause for concern.
C: Fingers tingling may be due to various reasons unrelated to the delivery process and is not a typical concern post vaginal delivery.
D: Thirst is a common symptom post-delivery and is not indicative of a serious complication.
The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.)
- A. Progesterone levels become higher than estrogen levels.
- B. Natural oxytocin in conjunction with other substances plays a role
- C. Stretching, pressure, and irritation of the uterus and cervix increase
- D. The secretion of prostaglandins from the fetal membranes decreases.
Correct Answer: B
Rationale: The correct answer is B: Natural oxytocin in conjunction with other substances plays a role in the initiation of labor. Oxytocin is a key hormone that stimulates uterine contractions during labor. Its release is crucial for the progression of labor. Other substances, such as prostaglandins, also play a role in initiating labor by softening the cervix and promoting contractions.
Rationale:
1. Oxytocin is a well-known hormone that directly stimulates uterine contractions, leading to the initiation of labor.
2. Prostaglandins are also important in preparing the cervix for labor and promoting contractions, which contradicts option D.
3. Progesterone levels decreasing and estrogen levels increasing typically signal the onset of labor, which contradicts option A.
4. Factors like stretching, pressure, and irritation of the uterus and cervix are more related to the progression of labor rather than the initiation, which contradicts option C.
In summary
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.
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 because in the fourth stage of labor, immediate postpartum bonding between parents and newborn is crucial. The nurse should respect the rapid psychologic changes by taking cues from the parents on how they want this bonding experience to unfold. This approach ensures that the parents are supported in establishing a strong emotional bond with their newborn, promoting a positive postpartum experience.
Choice A is incorrect because inviting the family in may not align with the parents' wishes for privacy during this intimate moment. Choice C is incorrect as asking multiple questions about taking pictures may be intrusive and disrupt the bonding process. Choice D is incorrect as separating the newborn from the parents can hinder bonding and may not align with current best practices in postpartum care.