Nokea
What is the nurse primarily concerned about maintaining in the initial care of the newborn?
- A. Fluid intake
- B. Feeding schedule
- C. Thermoregulation
- D. Parental bonding
Correct Answer: C
Rationale: Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.
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What marks the end of the third stage of labor?
- A. Full cervical dilation
- B. Expulsion of the placenta and membranes
- C. Birth of the infant
- D. Engagement of the head
Correct Answer: B
Rationale: The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.
What do late decelerations indicate?
- A. A nonreassuring pattern
- B. Uteroplacental insufficiency
- C. Fetal heart depression
- D. Cord compression
- E. Head compression
Correct Answer: A,B,C
Rationale: Late decelerations indicate a nonreassuring pattern, uteroplacental insufficiency, and fetal heart depression.
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.
After being given an explanation by the nursing instructor, what statement by the student indicates an accurate understanding of station?
- A. Fetal head is above the ischial spines.'
- B. Fetal head is below the ischial spines.'
- C. Fetal head is engaged in the mother's pelvis.'
- D. Fetal head is visible at the perineum.'
Correct Answer: A
Rationale: Station describes the level of the presenting part in the pelvis. Minus stations are above the ischial spines.
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.