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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A patient whose cervix is dilated to 6 cm is considered to be in which phase of labor?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Third stage
Correct Answer: B
Rationale: The correct answer is B: Active phase. In the active phase of labor, the cervix is typically dilated from 6 to 10 cm. This phase marks the transition from early labor to active labor, where contractions become stronger and more frequent, leading to further cervical dilation for the eventual delivery of the baby. The other choices are incorrect because:
A: Latent phase is typically from 0 to 6 cm dilation.
C: Second stage refers to the stage of labor starting from full dilation (10 cm) until the baby is born.
D: Third stage is the stage after the baby is born, focusing on the delivery of the placenta.
The patient with which vaginal exam is most at risk for an umbilical cord prolapse?
- A. 1-2 cm dilated, 70% effaced, -1 station
- B. 5 cm dilated, 60% effaced, -3 station
- C. 7-8 cm dilated, 80% effaced, -2 station
- D. 9 cm dilated, 100% effaced, 0 station
Correct Answer: B
Rationale: The correct answer is B because a patient who is 5 cm dilated, 60% effaced, and at -3 station is most at risk for umbilical cord prolapse. At this stage, the presenting part of the baby is relatively high in the pelvis, increasing the likelihood of the cord slipping past and becoming compressed against the cervix during contractions. This can lead to decreased blood flow and oxygen supply to the baby, posing a serious risk. Choices A, C, and D are less likely to result in cord prolapse due to the lower station of the baby in the pelvis, reducing the chance of cord compression.
A woman who is 39 weeks pregnant presents to the labor and delivery unit stating that she thinks she is in labor. Her contractions are irregular at 7 to 10 minutes apart. Which sign is definitive for true labor?
- A. Pain decreases when walking.
- B. Cervical dilation is occurring.
- C. The fetal membranes rupture.
- D. The fetal head is at –1 station.
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation is occurring. During true labor, the cervix begins to dilate and efface in preparation for childbirth. This process is a definitive sign of active labor. In contrast, the other choices are not definitive signs of true labor. Choice A is incorrect because pain decreasing when walking is not a specific indicator of true labor. Choice C, the fetal membranes rupturing, indicates the beginning of labor but is not the definitive sign. Choice D, the fetal head at –1 station, signifies the descent of the baby into the pelvis but does not confirm active labor.
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.
The patient with which vaginal exam is most at risk for an umbilical cord prolapse?
- A. 1-2 cm dilated, 70% effaced, -1 station
- B. 5 cm dilated, 60% effaced, -3 station
- C. 7-8 cm dilated, 80% effaced, -2 station
- D. 9 cm dilated, 100% effaced, 0 station
Correct Answer: B
Rationale: The correct answer is B because a patient who is 5 cm dilated, 60% effaced, and at -3 station is most at risk for an umbilical cord prolapse. At this stage, the presenting part of the baby is not well engaged in the pelvis, increasing the likelihood of the cord slipping down in front of the baby. This can lead to compression of the cord during labor, which is a serious obstetric emergency.
Choice A is less likely as the baby is only at -1 station and not as far down in the pelvis. Choice C also has the baby at a higher station (-2) and more dilated, which may help secure the baby's position. Choice D is the least likely as the baby is fully engaged at 0 station, reducing the risk of cord prolapse.