Nokea
The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient?
- A. By offering the patient warm fluids to drink
- B. By helping the patient to ambulate in the room
- C. By seating the patient upright in a straight-back chair
- D. By positioning the patient on her right side
Correct Answer: B
Rationale: Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
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The nurse knows that what indicates the beginning of true labor?
- A. Contractions that are relieved by walking
- B. Discomfort in the abdomen and groin
- C. A decrease in vaginal discharge
- D. Regular contractions becoming more frequent and intense
Correct Answer: D
Rationale: In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.
What is the nurse primarily concerned about maintaining in the initial care of the newborn?
- A. Fluid intake
- B. Feeding schedule
- C. Thermoregulation
- D. Parental bonding
Correct Answer: C
Rationale: Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.
It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. How would the nurse record this presentation?
- A. Complete breech
- B. Frank breech
- C. Double footing
- D. Buttocks presentation
Correct Answer: B
Rationale: When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.
What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?
- A. Fetal distress
- B. Fetal maturity
- C. Intact gastrointestinal tract
- D. Dehydration in the mother
Correct Answer: A
Rationale: Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.
Why is the relaxation phase between contractions important?
- A. The laboring woman needs to rest.
- B. The uterine muscles fatigue without relaxation.
- C. The contractions can interfere with fetal oxygenation.
- D. The infant progresses toward delivery at these times.
Correct Answer: C
Rationale: Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.