Nokea
Which assessment finding indicates that cervical dilation and/or effacement has occurred?
- A. Onset of irregular contractions
- B. Cephalic presentation at 0 station
- C. Bloody mucus drainage from vagina
- D. Fetal heart tones (FHTs) present in the lower right quadrant
Correct Answer: C
Rationale: Bloody mucus drainage from the vagina, also known as "bloody show," is a common sign that indicates cervical dilation and/or effacement has occurred in anticipation of labor. This occurs as the mucus plug, which seals the cervix during pregnancy, is released as the cervix begins to soften, dilate, and efface in preparation for childbirth. This physical change in the cervix is a significant indicator that labor is approaching. The other options listed do not directly indicate cervical changes associated with labor progression like the presence of bloody mucus drainage does.
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How can a nurse support the patient during the fourth stage of labor?
- A. Support pushing efforts with feedback on how much progress is being made
- B. Ensure epidural anesthesia is adequate for pain control, reposition frequently, provide dietary intake per provider's order.
- C. Assess for any bleeding or amniotic fluid presence in the vaginal discharge
- D. Provide rest, space, and time for bonding between assessments, support for feeding
preferences, diligent monitoring for complications, pain management.
Correct Answer: D
Rationale: During the fourth stage of labor, it is important for the nurse to provide a supportive and nurturing environment for the mother and baby. This stage occurs immediately after the baby is born and lasts for about 2 hours. The mother may be exhausted from the physical effort of labor and delivery, so providing rest, space, and time for bonding between assessments is crucial. The nurse should also support the mother's feeding preferences, whether it is breastfeeding or formula feeding. Diligent monitoring for complications, such as postpartum hemorrhage or infection, is essential during this stage. Additionally, providing adequate pain management for any discomfort the mother may be experiencing is important.
The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%/+1. What instruction will the nurse implement with the patient?
- A. "You will need to remain in bed attached to the electronic fetal monitor.”
- B. "Breathe with me slowly, in through your nose and out through your mouth.”
- C. "I will begin the administration of 1000 mL of IV fluid so you can have an epidural.”
- D. "Your partner will need to change into scrub attire to attend the imminent birth.”
Correct Answer: A
Rationale: The notation "3/50%/+" in the patient's record indicates that the patient is dilated 3 cm, the effacement is 50%, and the presenting part of the fetus is at +1 station. This information signifies that the patient is in active labor. The nurse should implement the instruction of having the patient remain in bed attached to the electronic fetal monitor to closely monitor the progression of labor and the well-being of the fetus. This will allow for continuous assessment and prompt interventions as needed.
During the second stage, what do the birthing person's vital signs most likely show?
- A. increased heart rate during contractions, baseline heart rate between contractions
- B. increased heart rate during contractions, decreased heart rate between contractions
- C. decreased heart rate during contractions, increased heart rate between contractions
- D. decreased heart rate during contractions, baseline heart rate between contractions
Correct Answer: A
Rationale: During the second stage of labor (pushing stage), the birthing person's vital signs most likely show an increased heart rate during contractions and a baseline heart rate between contractions. This increase in heart rate is a normal physiological response to the exertion and pressure of pushing during contractions. Between contractions, the heart rate should return to a more stable baseline. It is important to monitor these vital signs to ensure the well-being of both the birthing person and the baby during childbirth.
A nurse performs a vaginal examination on her patient in early labor and determines that the head is ballotable. What is this defined as?
- A. Floating
- B. Zero station
- C. +1 station
- D. -2 station
Correct Answer: A
Rationale: Ballotable means the fetal head is floating and can be pushed away from the cervix.
The onset of labor is multifactorial. These reasons include which of the following? Select all that apply.
- A. Increase in progesterone
- B. Increase in estrogen
- C. Increase in human chorionic gonadotropin
- D. Aging of placenta
Correct Answer: B
Rationale: Increase in progesterone, estrogen, aging of placenta, and fetal hormones are the factors contributing to the onset of labor.