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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.
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The nurse knows that what indicates the beginning of true labor?
- A. Contractions that are relieved by walking
- B. Discomfort in the abdomen and groin
- C. A decrease in vaginal discharge
- D. Regular contractions becoming more frequent and intense
Correct Answer: D
Rationale: In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.
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.
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 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.
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.