Nokea
Using Leopold maneuvers to assess fetal position the nurse finds a soft rounded prominence at the level of the fundus a hard round prominence just above the symphysis pubis and nodulations on the left side of the uterus. How should the nurse document the fetal position?
- A. Right occiput anterior (ROA) vertex
- B. Left occiput anterior (LOA) vertex
- C. Right occiput transverse (ROT) breech
- D. Left occiput anterior (LOA) breech
Correct Answer: A
Rationale: Fetal position can be determined by the Leopold maneuver, which defines the relationship of the presenting part to the maternal pelvis quadrant. A soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus indicate a right occiput anterior (ROA), vertex positioning.
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Why is the size and shape of the true pelvis more important than that of the false pelvis?
- A. The fetal head must be able to pass through the true pelvis.
- B. The true pelvis are the mother's measurements.
- C. The size of the false pelvis can change.
- D. The size of the true pelvis needs to be larger.
Correct Answer: A
Rationale: The size and shape of the true pelvis is more important than the false pelvis because the fetal head must be able to pass through for vaginal delivery to occur.
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.
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.
A nurse is assessing the printout from the fetal monitor. What is the legal responsibility of the nurse?
- A. Correctly identifying abnormal FHR patterns and prescribing medication
- B. Correctly identifying abnormal FHR patterns and notifying the health care provider
- C. The nurse is not legally responsible for fetal monitoring
- D. Providing technical assessment to the monitor technicians
Correct Answer: B
Rationale: Nurses are responsible for the timely notification of the primary caregiver in the event of an abnormal fetal heart rate (FHR) pattern. The nurse cannot write a medication order.
A primigravida patient is admitted to the labor and delivery unit. During initial assessment the baby is found to be engaged. Which statement is true?
- A. The narrowest diameter of the presenting part has reached the pelvic outlet.
- B. The descending part is being initiated through the midpelvis.
- C. The widest diameter of the presenting part crosses the pelvic inlet.
- D. The narrowest diameter of the presenting part is at the ischial spines.
Correct Answer: C
Rationale: Engagement occurs when the biparietal diameter, which is the widest part of the fetal head, crosses the pelvic inlet.