Nokea
What should the nurse consider when the birthing person has a decrease in blood pressure after the placenta is delivered?
- A. The birthing person is in pain.
- B. Place the newborn skin-to-skin.
- C. The bladder is distended
- D. Check for possible hemorrhage.
Correct Answer: E
Rationale: It seems like option E is missing from the choices provided. Could you please provide the correct options so that I can give you a detailed explanation for the correct answer?
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The labor and delivery nurse is caring for a 27-year-old primigravida with the following vaginal exam: 2 to 3 cm dilated/70% effaced/-2 station. For the last 2 hours the FHR tracing has displayed a Category I tracing and uterine contractions that are every 2 minutes. The contractions are strong to palpation and the patient is now 3/70%/-2. Which is the nurse’s next best action?
- A. Encourage the patient to ambulate
- B. Request orders to initiate oxytocin
- C. Assist the patient to a warm bath
- D. Document the findings
Correct Answer: D
Rationale: The correct answer is D, documenting the findings. In this scenario, the patient is in active labor with regular strong contractions, cervical change, and a reassuring fetal heart rate tracing. The priority is to document these important clinical findings accurately for proper assessment and monitoring of progress. Encouraging ambulation (A) may not be safe due to the frequency and strength of contractions. Initiating oxytocin (B) is unnecessary as labor is progressing well on its own. Assisting the patient to a warm bath (C) may provide comfort but is not the most critical action at this time.
The labor and delivery nurse is caring for a 27-year-old primigravida with the following vaginal exam: 2 to 3 cm dilated/70% effaced/-2 station. For the last 2 hours the FHR tracing has displayed a Category I tracing and uterine contractions that are every 2 minutes. The contractions are strong to palpation and the patient is now 3/70%/-2. Which is the nurse’s next best action?
- A. Encourage the patient to ambulate
- B. Request orders to initiate oxytocin
- C. Assist the patient to a warm bath
- D. Document the findings
Correct Answer: D
Rationale: The correct answer is D: Document the findings. In this scenario, the patient is in active labor with a Category I FHR tracing, optimal contractions, and progressing cervical dilation. Documenting the findings is important to maintain an accurate record of the patient's progress, which is crucial for monitoring labor and ensuring appropriate care. Encouraging ambulation (choice A) may be unnecessary or even unsafe given the frequency and strength of contractions. Initiating oxytocin (choice B) is not indicated as the patient is already in active labor. Assisting the patient to a warm bath (choice C) may provide comfort but is not the priority at this stage. Therefore, documenting the findings is the next best action to ensure proper documentation and monitoring of the patient's progress.
To determine if the patient is in true labor, the nurse would assess for changes in
- A. cervical dilation.
- B. amount of bloody show.
- C. fetal position and station.
- D. pattern of uterine contractions.
Correct Answer: D
Rationale: Step-by-step rationale:
1. The pattern of uterine contractions is crucial in determining true labor as true contractions are regular, increasing in frequency, duration, and intensity.
2. Assessing cervical dilation alone may not confirm true labor as some women may have cervical changes without being in active labor.
3. Bloody show may occur in both true and false labor, making it an unreliable indicator.
4. Fetal position and station are important for labor progression but do not definitively confirm true labor.
Therefore, by assessing the pattern of uterine contractions, the nurse can accurately determine if the patient is in true labor.
How long is the expected length of the third stage of labor?
- A. 60 minutes or less
- B. 30 minutes or less
- C. 1 hour for a multiparous person, 2 hours for a nulliparous person
- D. 3 hours for a multiparous person, 4 hours for a nulliparous person
Correct Answer: C
Rationale: The correct answer is C: 1 hour for a multiparous person, 2 hours for a nulliparous person. This is based on the typical duration of the third stage of labor, which involves the delivery of the placenta. In general, the third stage is expected to last around 5-30 minutes. However, for safety reasons and to allow for variations in individual cases, it is recommended to extend the time frame to 1 hour for multiparous individuals (those who have given birth before) and 2 hours for nulliparous individuals (those giving birth for the first time). This extended time frame ensures that healthcare providers have enough time to monitor and intervene if necessary without rushing the delivery of the placenta.
Other choices are incorrect because they provide either too short (A and B) or too long (D) timeframes for the third stage of labor, which could lead to inadequate monitoring or unnecessary interventions.
During an oxytocin induction, which assessment finding is most concerning to the labor and delivery nurse?
- A. A uterine resting tone of 17 mm Hg
- B. A uterine resting tone of 30 mm Hg
- C. Contractions that are every 3 minutes and last 60 seconds
- D. Contractions that are every 5 minutes and last 60 seconds
Correct Answer: B
Rationale: The correct answer is B because a uterine resting tone of 30 mm Hg indicates excessive uterine activity, which can lead to uterine hyperstimulation and fetal distress during an oxytocin induction. A higher resting tone suggests the uterus is not relaxing adequately between contractions, potentially compromising fetal oxygenation. Choices A, C, and D are incorrect because a uterine resting tone of 17 mm Hg is within the normal range, contractions every 3 minutes lasting 60 seconds and every 5 minutes lasting 60 seconds are typical patterns during labor induction, and they do not necessarily indicate complications.