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The nurse is directing an unlicensed assistive personnel (UAP) to obtain maternal vital signs between contractions. Which statement is the appropriate rationale for assessing maternal vital signs between contractions raNtheRr thaIn aGt anBot.heCr inMterval? U S N T O
- A. Vital signs taken during contractions are inaccurat
- B. During a contraction, assessing fetal heart rate is the priority.
- C. Maternal blood flow to the heart is reduced during contractions.
- D. Maternal circulating blood volume increases temporarily during contractions.
Correct Answer: D
Rationale: The correct answer is D. During contractions, maternal circulating blood volume increases temporarily due to the compression of blood vessels. Therefore, assessing vital signs between contractions provides a more accurate baseline measurement. Choice A is incorrect because vital signs taken during contractions may be affected by the pain and stress of labor. Choice B is incorrect as fetal heart rate assessment is a separate priority. Choice C is incorrect as maternal blood flow to the heart actually increases during contractions to ensure adequate oxygen supply.
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The nurse is planning care for a patient during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
- A. Offer the patient a warm blanket.
- B. Place an ice pack on the perineum.
- C. Massage the uterus if it is boggy.
- D. Delay breastfeeding until the patient is reste
Correct Answer: A
Rationale: The correct answer is A because offering the patient a warm blanket helps prevent hypothermia, which can occur due to heat loss during the delivery process. This intervention promotes patient comfort and helps maintain their body temperature.
Choice B is incorrect because placing an ice pack on the perineum is typically done in the immediate postpartum period to reduce swelling and discomfort, not during the fourth stage of labor.
Choice C is incorrect because massaging the uterus if it is boggy is a postpartum intervention to prevent or treat uterine atony, not typically performed during the fourth stage of labor.
Choice D is incorrect because delaying breastfeeding until the patient is rested is not necessary during the fourth stage of labor. Breastfeeding should be initiated as soon as possible after delivery to promote bonding and stimulate milk production.
During the COVID-19 pandemic, what was revealed about the importance of labor support?
- A. Labor support can only be provided by the significant other.
- B. Laboring patients did not need support from outside sources.
- C. Outcomes for birth were not changed by pandemic requirements.
- D. Patients during the pandemic's support ban experienced more depression.
Correct Answer: D
Rationale: The correct answer is D because patients who experienced a support ban during the pandemic were more likely to experience depression due to the lack of emotional and physical support during labor. This is supported by research showing the negative impact of isolation on mental health. Choices A and B are incorrect as labor support can come from various sources, not just the significant other, and patients benefit from support during labor. Choice C is incorrect as pandemic requirements did impact birth outcomes, such as increased stress and anxiety levels.
To determine if the patient is in true labor, the nurse would assess for changes in
- A. cervical dilation.
- B. amount of bloody show.
- C. fetal position and station.
- D. pattern of uterine contractions.
Correct Answer: D
Rationale: The correct answer is D: pattern of uterine contractions. This is because the pattern of contractions is a key indicator of true labor. True labor contractions are regular, increasing in frequency, duration, and intensity. Assessing the pattern helps differentiate true labor from false labor.
A: Cervical dilation is important but may not necessarily indicate true labor as it can occur in false labor as well.
B: The amount of bloody show is a sign of cervical changes, but it alone does not confirm true labor.
C: Fetal position and station are important for labor progress but do not definitively confirm true labor.
In summary, assessing the pattern of uterine contractions is crucial in determining true labor as it provides direct insight into the progression and intensity of contractions, distinguishing it from false labor.
What changes in hormones initiate labor?
- A. decreased progesterone, decreased estrogen, absence of oxytocin
- B. increased progesterone, decreased estrogen, absence of oxytocin
- C. increased progesterone, decreased estrogen, presence of oxytocin
- D. decreased progesterone, increased estrogen, effects of oxytocin
Correct Answer: D
Rationale: The correct answer is D because decreased progesterone, increased estrogen, and the effects of oxytocin are the hormonal changes that initiate labor. Progesterone inhibits contractions, so its decrease allows labor to begin. Estrogen promotes uterine sensitivity to oxytocin, which stimulates contractions. Oxytocin is released in response to labor contractions and helps to strengthen contractions.
A: Incorrect because decreased progesterone is needed for labor to start, estrogen needs to increase, and oxytocin is present during labor.
B: Incorrect because increased progesterone inhibits labor, estrogen should increase, and oxytocin is present during labor.
C: Incorrect because progesterone should decrease, estrogen should increase, and oxytocin is present during labor.
A fetus is positioned in a longitudinal lie with its head in the fundus with both hips and knees flexed. Which presentation is this known as?
- A. Frank breech
- B. Complete breech
- C. Vertex
- D. Transverse
Correct Answer: B
Rationale: The correct answer is B: Complete breech. In this presentation, the fetus is positioned with hips and knees flexed, and the head is in the fundus. This is different from a Frank breech where the hips are flexed but the knees are extended. Vertex presentation refers to the head being down and Transverse presentation is when the fetus is lying horizontally. In this case, the description matches the characteristics of a complete breech presentation, making it the correct answer.