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When caring for a woman with a complete placenta previa, which finding should the nurse report to the physician?
- A. BP of 95/60
- B. Temperature of 100.1°F
- C. Urine output of 40 mL/hour
- D. O2 saturation less that 95%
Correct Answer: D
Rationale: The correct answer is D: O2 saturation less than 95%. In placenta previa, the placenta covers the cervix, increasing the risk of bleeding. Decreased oxygen saturation can indicate poor perfusion due to bleeding, necessitating immediate medical attention. A: BP of 95/60 is relatively normal and not an urgent concern in this scenario. B: Temperature of 100.1°F may indicate an infection but is not directly related to placenta previa. C: Urine output of 40 mL/hour is within the normal range and does not directly impact the management of placenta previa.
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During the third stage of labor, what may the birthing person experience?
- A. expulsion of their fetus with vaginal bleeding
- B. cramping, gush of fresh vaginal bleeding, lengthening of the umbilical cord
- C. frequent episodes of dyspnea
- D. increased blood pressure and pain due to expulsive efforts
Correct Answer: B
Rationale: During the third stage of labor, the correct answer is B because it describes the typical experiences of the birthing person during this stage. Cramping signifies uterine contractions, a gush of fresh vaginal bleeding indicates the delivery of the placenta, and lengthening of the umbilical cord indicates separation from the placenta. The other options are incorrect as they do not align with the physiological processes of the third stage of labor. A is incorrect as the fetus is delivered in the second stage, not the third. C is incorrect as dyspnea (difficulty breathing) is not a common symptom during the third stage. D is incorrect as increased blood pressure and pain are not typical experiences during this stage.
A patient in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with
- A. more rapid labor.
- B. a high risk of infection.
- C. maternal perineal traum
- D. umbilical cord compression.
Correct Answer: D
Rationale: The correct answer is D: umbilical cord compression. In a breech presentation, the baby's bottom or feet present first, increasing the risk of umbilical cord prolapse or compression. This can lead to fetal distress due to compromised blood flow and oxygen supply. Other choices are incorrect as breech presentation is not associated with more rapid labor (A), high risk of infection (B), or increased maternal perineal trauma (C). It is crucial to prioritize addressing umbilical cord compression in a breech presentation to prevent potential complications for the baby.
A sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?
- A. Face presentation
- B. Breech presentation
- C. Vertex presentation
- D. Shoulder presentation
Correct Answer: A
Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) of the baby is the presenting part. This is a relatively rare presentation where the baby's head is extended, resulting in the face being the first part to be delivered. In a face presentation, the baby's head is hyperextended rather than flexed as in a vertex presentation. B: Breech presentation is when the baby's buttocks or feet are the presenting part. C: Vertex presentation is when the baby's head is the presenting part with the occiput leading the way. D: Shoulder presentation is when the baby's shoulder is the presenting part, which is a potentially dangerous situation requiring immediate medical intervention.
How should the nurse respect the rapid psychologic changes occurring in the fourth stage of labor?
- A. Invite the family to come in and see the newborn.
- B. Take the lead from the parents regarding interruption of the bonding.
- C. Ask multiple questions about taking pictures of the newborn.
- D. Take the newborn to the nursery to encourage the parents to rest.
Correct Answer: B
Rationale: The correct answer is B because in the fourth stage of labor, immediate postpartum bonding between parents and newborn is crucial. The nurse should respect the rapid psychologic changes by taking cues from the parents on how they want this bonding experience to unfold. This approach ensures that the parents are supported in establishing a strong emotional bond with their newborn, promoting a positive postpartum experience.
Choice A is incorrect because inviting the family in may not align with the parents' wishes for privacy during this intimate moment. Choice C is incorrect as asking multiple questions about taking pictures may be intrusive and disrupt the bonding process. Choice D is incorrect as separating the newborn from the parents can hinder bonding and may not align with current best practices in postpartum care.
If a notation on the patient’s health record states that the fetal position is LSP, this indicates that the
- A. head is in the right posterior quadrant of the pelvis.
- B. head is in the left anterior quadrant of the pelvis.
- C. buttocks are in the left posterior quadrant of the pelvis.
- D. buttocks are in the right upper quadrant of the abdomen.
Correct Answer: C
Rationale: The correct answer is C because LSP stands for Left Sacrum Posterior, indicating the baby's buttocks are in the left posterior quadrant of the pelvis. In this position, the baby's head will typically be in the right anterior quadrant of the pelvis. Choice A is incorrect as it describes the head in the right posterior quadrant. Choice B is incorrect as it describes the head in the left anterior quadrant. Choice D is incorrect as it describes the buttocks in the right upper quadrant of the abdomen, which is not related to the fetal position LSP.