Nokea
The nurse is teaching a prenatal class about labor. What statement indicates understanding?
- A. True labor contractions are irregular and stop with rest.
- B. False labor contractions cause cervical dilation.
- C. True labor contractions increase in intensity and frequency.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor contractions become progressively stronger and lead to cervical dilation and effacement.
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What is the recommended response for a pregnant client reporting decreased fetal movements?
- A. Encourage the client to lie on her left side
- B. Schedule an immediate ultrasound
- C. Advise monitoring for fetal heart rate decelerations
- D. Instruct the client to monitor movements over the next 48 hours
Correct Answer: C
Rationale: Encouraging the client to monitor fetal movements can help identify any abnormalities early.
A laboring patient's obstetrician suggested an amniotomy as a method for inducing the labor. Which assessment must be made before the amniotomy is performed?
- A. Fetal presentation, position, and station
- B. Estimate fetal birth weight
- C. Maternal temperature, BP, pulse
- D. Biparietal diameter
Correct Answer: A
Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.
The patient asks the nurse when her Nexplanon can be inserted. How does the nurse respond?
- A. after the delivery of your placenta
- B. only during your period
- C. while you are in labor
- D. during the delivery
Correct Answer: A
Rationale: The nurse would respond with option A, "after the delivery of your placenta." Nexplanon is a hormonal contraceptive implant that is typically inserted in the upper arm subdermally. It is recommended to wait until after the delivery of the placenta to reduce the risk of causing any harm to the fetus during pregnancy or labor. Inserting Nexplanon during labor or delivery is not recommended due to the potential risks involved.
The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2–3 minutes.
- B. Contractions lasting 120 seconds.
- C. Baseline fetal heart rate of 140 beats/minute.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation and can compromise fetal oxygenation.
A pregnant client asks about the purpose of taking folic acid. What is the nurse's best response?
- A. It prevents gestational diabetes.
- B. It helps prevent neural tube defects.
- C. It supports fetal bone development.
- D. It reduces the risk of preterm labor.
Correct Answer: B
Rationale: Folic acid is essential for preventing neural tube defects like spina bifida during early fetal development.