Nokea
What is a direct influence on cervical dilation? Select all that apply.
- A. positioning of the pregnant person
- B. strength of uterine contractions
- C. length of time since ROM
- D. fetal presentation
Correct Answer: A
Rationale: The correct answer is A because the positioning of the pregnant person affects the alignment of the baby's head in the pelvis, directly influencing cervical dilation. Proper positioning helps the baby apply pressure to the cervix, promoting dilation. In contrast, the strength of uterine contractions (B) affects labor progress but not cervical dilation specifically. The length of time since ruptured membranes (C) may increase infection risk but does not directly impact dilation. Fetal presentation (D) affects the descent of the baby, not cervical dilation.
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During the third stage of labor, what may the birthing person experience?
- A. expulsion of their fetus with vaginal bleeding
- B. cramping, gush of fresh vaginal bleeding, lengthening of the umbilical cord
- C. frequent episodes of dyspnea
- D. increased blood pressure and pain due to expulsive efforts
Correct Answer: B
Rationale: During the third stage of labor, the birthing person may experience cramping, a gush of fresh vaginal bleeding, and lengthening of the umbilical cord. This is due to the delivery of the placenta. Cramping helps expel the placenta, fresh vaginal bleeding is normal after delivery, and the lengthening of the umbilical cord indicates that the placenta is detaching. Choices A, C, and D are incorrect as they do not accurately describe the typical experiences during the third stage of labor.
A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
- A. A nitrazine test is the most conclusive test.
- B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.
- C. Ferning is more conclusive than nitrazine paper testing.
- D. Note if there is fluid leaking from the perineal area.
Correct Answer: A
Rationale: The correct answer is A: A nitrazine test is the most conclusive test. The rationale for this is as follows:
1. Nitrazine test detects the pH level of the fluid. Amniotic fluid is alkaline while urine is acidic.
2. Amniotic fluid will turn the nitrazine paper blue, indicating a pH level greater than 6.5, while urine will not change the color significantly.
3. This test is reliable and can help differentiate between amniotic fluid and urine leakage.
Summary of other choices:
B: Although nitrazine paper changes color due to the acidic nature of amniotic fluid, it is not a comprehensive test on its own.
C: Ferning test is not commonly used in practice and may not be as reliable as the nitrazine test.
D: Noting if fluid is leaking from the perineal area does not provide a conclusive determination of whether it is amniotic fluid or urine.
The nurse is caring for a 34-year-old gravida 4, para 3 experiencing a prolonged labor. The physician performed an amniotomy 3 hours ago to stimulate the progression of labor. The patient’s most recent vaginal exam was 8/80%/0. Which assessment finding should the nurse should be most concerned about?
- A. Pain score of 7/10
- B. FHR baseline of 165
- C. Mild variable decelerations
- D. Increased bloody mucous discharge
Correct Answer: B
Rationale: The correct answer is B: FHR baseline of 165. A baseline FHR above 160 is considered tachycardia in labor, which could indicate fetal distress. This finding is concerning as it may suggest fetal hypoxia or other complications, requiring immediate attention to prevent adverse outcomes. The other options are less concerning:
A: Pain score of 7/10 is subjective and expected during labor.
C: Mild variable decelerations are common in labor and may not immediately indicate distress.
D: Increased bloody mucous discharge is a normal finding post-amniotomy and not necessarily indicative of fetal distress.
A sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?
- A. Face presentation
- B. Breech presentation
- C. Vertex presentation
- D. Shoulder presentation
Correct Answer: A
Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) of the baby is the presenting part. This is a relatively rare presentation where the baby's head is extended, resulting in the face being the first part to be delivered. In a face presentation, the baby's head is hyperextended rather than flexed as in a vertex presentation. B: Breech presentation is when the baby's buttocks or feet are the presenting part. C: Vertex presentation is when the baby's head is the presenting part with the occiput leading the way. D: Shoulder presentation is when the baby's shoulder is the presenting part, which is a potentially dangerous situation requiring immediate medical intervention.
A laboring patient states to the nurse, "I have to push!” What is the next nursing action?
- A. Contact the health care provider.
- B. Examine the patient’s cervix for dilation.
- C. Review with her how to bear down with contractions.
- D. Ask her partner to support her head with each push.
Correct Answer: B
Rationale: The correct answer is B: Examine the patient’s cervix for dilation. This is the next nursing action because assessing cervical dilation is crucial in determining the progress of labor and if the patient is ready to push effectively. Contacting the health care provider (A) may cause unnecessary delays. Reviewing how to bear down with contractions (C) should be done after confirming cervical dilation. Asking her partner to support her head (D) is not the immediate priority in this situation.