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What does the nurse note when measuring the frequency of a laboring woman's contractions?
- A. How long the patient states the contractions last
- B. The time between the end of one contraction and the beginning of the next
- C. The time between the beginning and the end of one contraction
- D. The time between the beginning of one contraction and the beginning of the next
Correct Answer: D
Rationale: The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.
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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.
Why should the nurse encourage the mother to void during the fourth stage of labor?
- A. A full bladder could interfere with cervical dilation.
- B. A full bladder could obstruct progress of the infant through the birth canal.
- C. A full bladder could obstruct the passage of the placenta.
- D. A full bladder could predispose the mother to uterine hemorrhage.
Correct Answer: D
Rationale: A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.
What will the nurse remind the patient about contractions during this stage of labor?
- A. They get the infant positioned for delivery.
- B. They push the infant into the vagina.
- C. They dilate and efface the cervix.
- D. They get the mother prepared for true labor.
Correct Answer: C
Rationale: The first stage of labor describes the time from the onset of labor until full dilation of the cervix.
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.
One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action?
- A. Check the fundus for position and firmness.
- B. Report to the doctor immediately.
- C. Change the pads and chart the time.
- D. Time how long it takes to soak one pad.
Correct Answer: A
Rationale: Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.