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What tion in the FHR that is abrupt and appears to be does the nurse inform this group that they are at in the shape of a W. What is the most likely cause highest risk for? of this?
- A. Sexually transmitted diseases
- B. Compression of the fetal head
- C. Uterine cancer
- D. Compression of the umbilical cord
Correct Answer: D
Rationale: An abnormality in the FHR that is abrupt and appears to be in the shape of a "W" is often indicative of variable decelerations. Variable decelerations typically occur due to compression of the umbilical cord, leading to a temporary decrease in oxygen supply to the fetus. It is important for the nurse to inform this group that they are at the highest risk for compression of the umbilical cord as this can result in fetal distress and potentially lead to serious complications if not promptly addressed.
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A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
The laboring person asks the nurse to review the birth plan. What item is on a typical birth plan?
- A. where the patient will be staying after birth
- B. who will be watching their other children
- C. what position they want to birth in
- D. how they will time contractions
Correct Answer: C
Rationale: Birth plans often include preferences for birthing positions to promote comfort and effectiveness.
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor
- A. Cervical dilation
- B. Report of pain above the umbilicus
- C. Brownish vaginal discharge
- D. Amniotic fluid in the vaginal vault
Correct Answer: A
Rationale: Cervical dilation is a key physiological change that confirms labor has begun. During the late stages of pregnancy, the cervix starts to soften, thin out (efface), and open up (dilate) in preparation for childbirth. Therefore, cervical dilation is a critical finding that indicates the onset of labor. Pain above the umbilicus, brownish vaginal discharge, and amniotic fluid in the vaginal vault are not definitive signs of labor and do not confirm the initiation of the labor process.
A woman has been in labor for 16 hours. Her cervix is dilated
- A. The fetal presenting part is not engage
- B. The nurse would expect which malpresentation
- C. CPD (prevents presenting part form becoming engage
Correct Answer: A
Rationale: If a woman has been in labor for 16 hours and her cervix is not dilated, it suggests that the fetal presenting part is not engaged. Engagement refers to the descent of the fetal presenting part (usually the head) into the pelvis. When the presenting part is not engaged, it may lead to a prolonged labor as the fetus needs to descend further for labor to progress effectively. This can result in slower cervical dilation and may require interventions to help facilitate engagement, such as position changes or use of gravity-assisted techniques.
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.