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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.
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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.
When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the woman's change in behavior?
- A. Labor has progressed to the transition phase.
- B. She lacked adequate preparation for the labor experience.
- C. The woman would benefit from a different form of analgesia.
- D. The contractions have increased from mild to moderate intensity.
Correct Answer: A
Rationale: If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.
At 1 and 5 minutes of life, a newborn's Apgar score is 9. What does the nurse understand that a score of 9 indicates?
- A. The newborn will require resuscitation.
- B. The newborn may have physical disabilities.
- C. The newborn will have above average intelligence.
- D. The newborn is in stable condition.
Correct Answer: D
Rationale: Apgar scoring evaluates the infant's need for resuscitation. A score of 9 indicates that the newborn is stable.
It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. How would the nurse record this presentation?
- A. Complete breech
- B. Frank breech
- C. Double footing
- D. Buttocks presentation
Correct Answer: B
Rationale: When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.
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.