Nokea
The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?
- A. A well-oxygenated fetus
- B. Compression of the umbilical cord
- C. Compression of the fetal head
- D. Uteroplacental insufficiency
Correct Answer: A
Rationale: Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.
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The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?
- A. Pain related to increasing frequency and intensity of contractions
- B. Fear related to the probable need for cesarean delivery
- C. Dysuria related to prolonged labor and decreased intake
- D. Risk for injury related to hemorrhage
Correct Answer: D
Rationale: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
What contraction duration and interval does the nurse recognize could result in fetal compromise?
- A. Duration shorter than 30 seconds, interval longer than 75 seconds
- B. Duration shorter than 90 seconds, interval longer than 120 seconds
- C. Duration longer than 90 seconds, interval shorter than 60 seconds
- D. Duration longer than 60 seconds, interval shorter than 90 seconds
Correct Answer: C
Rationale: Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.
What is the best nursing action to implement when late decelerations occur?
- A. Reposition the patient to supine.
- B. Decrease flow of intravenous (IV) fluids.
- C. Increase oxygen to 10 L/minute.
- D. Prepare to increase oxytocin drip.
Correct Answer: C
Rationale: The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.
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.
The nurse observes the patient bearing down with contractions and crying out, 'The baby is coming!' What is the best nursing intervention?
- A. Find the physician.
- B. Stay with the woman and use the call bell to get help.
- C. Send the woman's partner to locate a registered nurse.
- D. Assist with deep breathing to slow the labor process.
Correct Answer: B
Rationale: If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.