Nokea
What signs and symptoms would lead the nurse to suspect false (prodromal) labor?
- A. Leaking of vaginal fluid
- B. Contractions intensify with ambulation
- C. Pink spotting
- D. Painless tightening of abdominal muscles
- E. Cervix thick and not effaced
Correct Answer: D,E
Rationale: Painless tightening of abdominal muscles (Braxton Hicks contractions) and a cervix that is thick and not effaced indicate false (prodromal) labor.
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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.
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 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 is the best nursing action to implement when late decelerations occur?
- A. Reposition the patient to supine.
- B. Decrease flow of intravenous (IV) fluids.
- C. Increase oxygen to 10 L/minute.
- D. Prepare to increase oxytocin drip.
Correct Answer: C
Rationale: The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.
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.