Nokea
Which assessment finding would cause a concern for a patient who had delivered vaginally?
- A. Estimated blood loss (EBL) of 500 mL during the birth process
- B. White blood cell count of 28,000 mm3 postbirth
- C. Patient complains of fingers tingling
- D. Patient complains of thirst
Correct Answer: B
Rationale: The correct answer is B because a white blood cell count of 28,000 mm3 postbirth indicates a possible infection, such as endometritis, which is a common postpartum complication. Elevated WBC count is a sign of an inflammatory process or infection, requiring further investigation and treatment.
A: EBL of 500 mL is within the normal range for a vaginal delivery and may not necessarily indicate a concern.
C: Patient complaints of fingers tingling may suggest temporary nerve compression or positional discomfort, not a significant concern post vaginal delivery.
D: Patient complaining of thirst is a common symptom and not necessarily indicative of a complication post vaginal delivery.
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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.
The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
- A. Powers
- B. Passage
- C. Position
- D. Passenger
Correct Answer: A
Rationale: The correct answer is A: Powers. The four Ps of childbirth are Powers, Passage, Passenger, and Psyche. Powers refer to the contractions of the uterus and the pushing efforts of the mother during labor. Passage involves the birth canal through which the baby passes. Passenger refers to the fetus and its position during labor. Psyche relates to the psychological aspects of labor. In this case, Powers directly interact during childbirth by facilitating the progress of labor. Passage, Position, and Passenger are important factors as well, but they do not directly interact during childbirth like Powers do.
A 29-year-old gravida 1, para 0 woman who is 35 weeks pregnant is admitted to the labor and delivery unit. She states that there is fluid leaking from her vagina but she is not sure if it is urine. What should the nurse do to make the determination?
- A. A nitrazine test is the most conclusive test.
- B. Nitrazine paper changes from yellow to dark blue due to the acidic nature of amniotic fluid.
- C. Ferning is more conclusive than nitrazine paper testing.
- D. Note if there is fluid leaking from the perineal area.
Correct Answer: A
Rationale: The correct answer is A. The nurse should perform a nitrazine test to determine if the fluid leaking is amniotic fluid. Here's the rationale:
1. Nitrazine test is specifically designed to differentiate amniotic fluid from urine.
2. Amniotic fluid is alkaline, causing the nitrazine paper to turn blue when it comes into contact with it.
3. Urine, on the other hand, does not change the color of the nitrazine paper.
4. This test is quick, easy to perform, and provides a conclusive result in differentiating amniotic fluid from other fluids.
In summary:
- Choice B incorrectly describes the color change mechanism of nitrazine paper.
- Choice C refers to ferning, which is not as conclusive as the nitrazine test.
- Choice D does not provide a definitive method for determining if the leaking fluid is amniotic fluid.
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, meaning the baby's back is on the left side of the mother's spine and facing towards her back. This position is common during the early stages of labor. Choice A is incorrect as it describes a different position, choice B is incorrect as it refers to a different quadrant, and choice D is incorrect as it describes a location in the abdomen, not the pelvis.
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. The nurse should initiate external fetal monitoring to assess the fetus's heart rate and uterine contractions, given the patient's history of placenta previa and vaginal bleeding. This helps to monitor the well-being of the fetus and detect any signs of distress. Performing a vaginal examination (Choice A) may aggravate the placenta previa and increase the risk of bleeding. Artificial rupture of membranes (Choice B) is contraindicated in cases of placenta previa due to the risk of increased bleeding. Encouraging ambulation (Choice D) is not advisable in this situation as it may also worsen bleeding.