Nokea
The patient's membranes have just ruptured. What is the first priority of the nurse?
- A. Turn the patient on the left side.
- B. Perform a Nitrazine test.
- C. Check the fetal heart rate (FHR).
- D. Perform a vaginal examination.
Correct Answer: C
Rationale: The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby.
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When observing the fetal heart monitor the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse?
- A. Early deceleration due to head compression
- B. That the fetus is in acute distress
- C. Variable decelerations due to cord compression
- D. That these are late decelerations
Correct Answer: A
Rationale: This indicates early decelerations because of head compression.
A pregnant woman is discussing her desire to have her baby in a birthing center. Which factors could exclude the patient from delivering in a birthing center?
- A. The patient is a primigravida.
- B. The patient will be having a planned cesarean delivery.
- C. The mother has preeclampsia.
- D. The baby is a boy.
- E. The mother has no support system.
Correct Answer: B,C
Rationale: Birthing centers are ideal only for women who are considered low risk. Cesarean deliveries would not be done in a birthing center. The mother with preeclampsia would be considered high risk and would probably be excluded from delivering in the birthing center. The number of previous pregnancies, sex of the baby, and mother's support system would not be factors considered when determining risk for delivering in a birthing center.
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time?
- A. Cool fluids to drink
- B. A backrub in the sacral area
- C. Assisting to lie in a supine position
- D. Decreasing illumination in the room
Correct Answer: B
Rationale: Backache in the sacral area is a common complaint during the first stage of labor. The keyword is "comfort" in the question. Providing a backrub is providing comfort to the laboring patient.
Why is oxytocin administered in the third stage of labor?
- A. To stimulate lactation
- B. To relieve postpartum pain
- C. To stimulate uterine contractions
- D. To sedate the mother so she can rest
Correct Answer: C
Rationale: Oxytocin makes the uterus contract and reduces postpartum hemorrhage.
What area of the uterus provides the force during a contraction?
- A. Lower portion
- B. Middle portion
- C. Upper portion
- D. Cervical portion
Correct Answer: C
Rationale: The upper portion of the uterus provides the force during contractions.