Nokea
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.
You may also like to solve these questions
What is the nurse primarily concerned about maintaining in the initial care of the newborn?
- A. Fluid intake
- B. Feeding schedule
- C. Thermoregulation
- D. Parental bonding
Correct Answer: C
Rationale: Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.
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.
One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action?
- A. Check the fundus for position and firmness.
- B. Report to the doctor immediately.
- C. Change the pads and chart the time.
- D. Time how long it takes to soak one pad.
Correct Answer: A
Rationale: Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.
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.