Nokea
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.
You may also like to solve these questions
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 function of contractions during the second stage of labor?
- A. Align the infant into the proper position for delivery.
- B. Dilate and efface the cervix.
- C. Push the infant out of the mother's body.
- D. Separate the placenta from the uterine wall.
Correct Answer: C
Rationale: The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant.
Why is the relaxation phase between contractions important?
- A. The laboring woman needs to rest.
- B. The uterine muscles fatigue without relaxation.
- C. The contractions can interfere with fetal oxygenation.
- D. The infant progresses toward delivery at these times.
Correct Answer: C
Rationale: Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.
The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient?
- A. By offering the patient warm fluids to drink
- B. By helping the patient to ambulate in the room
- C. By seating the patient upright in a straight-back chair
- D. By positioning the patient on her right side
Correct Answer: B
Rationale: Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
What is the most important nursing intervention during the fourth stage of labor?
- A. Monitor the frequency and intensity of contractions.
- B. Provide comfort measures.
- C. Assess for hemorrhage.
- D. Promote bonding.
Correct Answer: C
Rationale: Immediately after giving birth, every woman is assessed for signs of hemorrhage.