Nokea
When does the second stage of labor begin?
- A. at birth
- B. when the early phase ends
- C. when the cervix is completely dilated and effaced
- D. when pushing begins
Correct Answer: D
Rationale: The correct answer is D: when pushing begins. The second stage of labor begins when the cervix is fully dilated, and the mother starts pushing to deliver the baby. This stage ends with the birth of the baby. Option A is incorrect because the second stage begins after birth. Option B is incorrect as it refers to the transition phase, not the second stage. Option C is incorrect because the cervix being fully dilated and effaced marks the beginning of the second stage, not the end of it.
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A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
- A. The biparietal diameter of the fetal head is at the level of the ischial spines.
- B. The biparietal diameter of the fetal head is at –2 station.
- C. The fetal head is well flexed.
- D. The fetal head is unable to pass under the pubic arch.
Correct Answer: A
Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.
Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
- A. Extension
- B. Engagement
- C. Internal rotation
- D. External rotation
Correct Answer: B
Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part passes through the pelvic inlet, indicating the descent of the fetal head into the pelvis. This is a crucial step in labor progress as it signifies the baby's readiness for birth.
A: Extension occurs during the second stage of labor when the baby's head passes through the birth canal.
C: Internal rotation is the movement of the baby's head within the pelvis to align with the maternal pelvis.
D: External rotation happens after the baby's head is delivered to allow for the shoulders to rotate for birth.
In summary, engagement is the correct answer as it specifically refers to the largest diameter of the fetal presenting part passing the pelvic inlet, setting the stage for the progression of labor.
The nurse is caring for a 34-year-old gravida 4, para 3 experiencing a prolonged labor. The physician performed an amniotomy 3 hours ago to stimulate the progression of labor. The patient’s most recent vaginal exam was 8/80%/0. Which assessment finding should the nurse should be most concerned about?
- A. Pain score of 7/10
- B. FHR baseline of 165
- C. Mild variable decelerations
- D. Increased bloody mucous discharge
Correct Answer: B
Rationale: The correct answer is B: FHR baseline of 165. In this scenario, a FHR baseline of 165 is concerning as it is higher than the normal range (110-160 bpm) for a term fetus. This may indicate fetal distress or hypoxia, possibly due to cord compression or placental insufficiency. High baseline FHR can lead to fetal complications like acidosis or asphyxia. The other choices are less concerning: A is subjective and manageable, C indicates a common response to labor and is usually transient, and D is expected after amniotomy. Monitoring and addressing the abnormal FHR is crucial for fetal well-being.
A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?
- A. Perform a vaginal examination to determine cervical dilation
- B. Assist the health care provider to perform artificial rupture of the membranes
- C. Initiate external fetal monitoring
- D. Encourage patient to ambulate to intensify labor
Correct Answer: C
Rationale: The correct answer is C: Initiate external fetal monitoring. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.
The nurse is caring for a patient during the first stage of labor. What is an abnormal finding?
- A. patient moaning with contractions
- B. contractions 3 minutes apart lasting 60 seconds
- C. blood pressure 142/88
- D. respiratory rate 22
Correct Answer: C
Rationale: The correct answer is C because a blood pressure of 142/88 is considered high and abnormal during the first stage of labor. This could indicate hypertension, which can have serious implications for both the mother and the baby. High blood pressure can lead to complications such as preeclampsia.
A, B, and D are incorrect because:
A: Patient moaning with contractions is a common response to labor pains and does not necessarily indicate an abnormal finding.
B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor.
D: A respiratory rate of 22 is also within the normal range and is not indicative of any abnormal findings during the first stage of labor.