Nokea
The nurse is monitoring a patient in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)
- A. Maternal hypotension
- B. Fetal heart rate of 140 to 150 bpm
- C. Meconium-stained amniotic fluid
- D. Maternal fever"”38°C (100.4°F) or higher
Correct Answer: A
Rationale: The correct answer is A: Maternal hypotension. Maternal hypotension can lead to decreased perfusion to the placenta, compromising fetal oxygenation. Other choices are incorrect. B: A fetal heart rate of 140 to 150 bpm is within the normal range during labor. C: Meconium-stained amniotic fluid may indicate fetal distress but is not a direct condition associated with fetal compromise. D: Maternal fever can indicate infection but does not directly indicate fetal compromise in the active stage of labor.
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A patient in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with
- A. visceral pain.
- B. tissue ischemi
- C. cervical dilation.
- D. somatic pain.
Correct Answer: D
Rationale: The correct answer is D: somatic pain. Somatic pain is caused by the activation of pain receptors in the skin, muscles, or bones. In the second stage of labor, the baby's head passes through the birth canal, stretching the pelvic floor muscles and causing pressure and stretching of the perineum. This results in somatic pain due to the activation of pain receptors in these structures. Visceral pain (choice A) is deep, dull pain from internal organs, not applicable here. Tissue ischemia (choice B) refers to inadequate blood supply causing tissue damage, not pain. Cervical dilation (choice C) is not typically associated with burning pain.
Which patient at term should proceed to the hospital or birth center the immediately after labor begins?
- A. Gravida 2, para 1, who lives 10 minutes away
- B. Gravida 1, para 0, who lives 40 minutes away
- C. Gravida 2, para 1, whose first labor lasted 16 hours
- D. Gravida 3, para 2, whose longest previous labor was 4 hours
Correct Answer: D
Rationale: The correct answer is D because the patient is gravida 3, para 2, with a history of the shortest previous labor of 4 hours. This indicates a high likelihood of rapid labor progression, necessitating immediate hospital or birth center access to ensure timely delivery. Choice A lives 10 minutes away, which may not be enough time in case of rapid labor. Choice B, living 40 minutes away, poses a risk of delivering en route. Choice C's previous labor duration of 16 hours suggests a longer labor, making immediate hospital arrival less critical.
What would the nurse administer if the newborn has decreased or no respiratory effort at delivery after the person received an opiate?
- A. naloxone (Narcan)
- B. acetaminophen (Tylenol)
- C. oxygen
- D. sodium bicarbonate
Correct Answer: A
Rationale: The correct answer is A: naloxone (Narcan). If a newborn has decreased or no respiratory effort after the mother received an opiate, it indicates potential opiate toxicity in the newborn. Naloxone is an opioid antagonist that can reverse the effects of opiates, including respiratory depression. Administering naloxone can help stimulate the newborn's respiratory effort, promoting adequate oxygenation.
Summary:
- A: Naloxone is the correct answer as it reverses opiate effects.
- B: Acetaminophen is a pain reliever and does not address respiratory depression.
- C: Oxygen may help with oxygenation but does not address the underlying opiate toxicity.
- D: Sodium bicarbonate is used to treat acid-base imbalances and does not address opiate toxicity or respiratory depression.
The nurse is reviewing the cardinal maneuvers of labor and birth with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head?
- A. Expulsion
- B. Restitution
- C. Internal rotation
- D. External rotation
Correct Answer: A
Rationale: After the baby's head is born, the immediate next step is the expulsion of the baby's body. This is because the expulsion maneuver refers to the delivery of the rest of the baby's body following the birth of the head. Restitution, internal rotation, and external rotation occur before the birth of the baby's head and are part of the cardinal movements of labor and birth. Restitution involves the realignment of the baby's head with their body after the head is born. Internal rotation refers to the baby's head turning to navigate through the birth canal. External rotation involves the baby's head turning back to its original position after delivery. So, the correct answer is A (Expulsion), as it directly follows the birth of the baby's head.
If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to
- A. massage the fundus.
- B. take the blood pressure
- C. increase blood supply to the hands and feet.
- D. notify the physician or nurse-midwif
Correct Answer: A
Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.