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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.
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What is the nurse's most informative response?
- A. When you feel increased fetal movement
- B. When contractions are 10 minutes apart
- C. When membranes have ruptured
- D. When abdominal or groin discomfort occurs
Correct Answer: C
Rationale: Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
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.
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.
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.
Why is the relaxation phase between contractions important?
- A. The laboring woman needs to rest.
- B. The uterine muscles fatigue without relaxation.
- C. The contractions can interfere with fetal oxygenation.
- D. The infant progresses toward delivery at these times.
Correct Answer: C
Rationale: Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.