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 - White blood cell count of 28,000 mm3 postbirth. This finding indicates a possible infection or inflammation, which can be concerning after vaginal delivery. A high white blood cell count may suggest an ongoing infection that needs immediate attention.
A: Estimated blood loss of 500 mL is within normal range for vaginal delivery and is not a cause for concern.
C: Fingers tingling may be due to various reasons unrelated to the delivery process and is not a typical concern post vaginal delivery.
D: Thirst is a common symptom post-delivery and is not indicative of a serious complication.
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A gravida 2, para 1 is in active labor at 39 weeks gestation. Her cervical exam is 6 cm dilated, 60% effaced, and 0 station. An amniotomy is performed by the physician. The fluid is noted to be bloody and the fetal heart tones have decelerated to the 50s. What is the nurse’s next best action?
- A. Notify the operating team of emergent cesarean delivery
- B. Assist the patient to left lateral position
- C. Apply O2 at 10-12 L/min per nonrebreather
- D. Administer an IV fluid bolus
Correct Answer: A
Rationale: The correct answer is A: Notify the operating team of emergent cesarean delivery. Given the scenario of a gravida 2, para 1 in active labor with bloody fluid and fetal heart decelerations to the 50s following amniotomy, these signs indicate fetal distress. In this critical situation, immediate intervention with emergent cesarean delivery is necessary to prevent adverse outcomes for the baby. This step takes priority over other actions, as it ensures timely delivery and assessment of the fetus's well-being. Choices B, C, and D are not appropriate in this emergent situation as they do not directly address the fetal distress and the need for expedited delivery.
During the third stage of labor, what may the birthing person experience?
- A. expulsion of their fetus with vaginal bleeding
- B. cramping, gush of fresh vaginal bleeding, lengthening of the umbilical cord
- C. frequent episodes of dyspnea
- D. increased blood pressure and pain due to expulsive efforts
Correct Answer: B
Rationale: During the third stage of labor, the birthing person may experience cramping, a gush of fresh vaginal bleeding, and lengthening of the umbilical cord. This is due to the delivery of the placenta. Cramping helps expel the placenta, fresh vaginal bleeding is normal after delivery, and the lengthening of the umbilical cord indicates that the placenta is detaching. Choices A, C, and D are incorrect as they do not accurately describe the typical experiences during the third stage of labor.
Which of the following is a function of a doula during labor?
- A. Administration of oral pain medications
- B. Assess fetal heart rate
- C. Perform vaginal examination with the mother’s permission
- D. Provide nonpharmacological pain relief
Correct Answer: D
Rationale: The correct answer is D: Provide nonpharmacological pain relief. A doula's role is to offer emotional support, comfort measures, and advocacy during labor. Providing nonpharmacological pain relief techniques such as massage, breathing exercises, and positioning is within the scope of a doula's practice. This helps the mother cope with labor discomfort without the use of medication.
Choice A is incorrect because doulas do not administer medications. Choice B is incorrect as assessing fetal heart rate is typically done by healthcare providers. Choice C is incorrect as performing vaginal examinations is not a part of a doula's role.
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 because the second stage of labor begins when the mother starts pushing to deliver the baby. This stage involves the actual delivery of the baby and ends with the birth. The other choices are incorrect because:
A: Labor begins before the second stage.
B: The early phase is part of the first stage of labor.
C: Full dilation and effacement mark the transition between the first and second stages but pushing is when the second stage actually begins.
The nurse is caring for a gravida 5, para 4 who has been 5 centimeters dilated for 2 hours. The uterine contractions are every 5 minutes and mild to palpation. Which is the most appropriate nursing action?
- A. Administer ordered IV pain medicine
- B. Assist the patient with frequent position changes
- C. Prepare patient for epidural anesthesia
- D. Prepare patient for a cesarean section delivery
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with frequent position changes. This is because the patient is already 5cm dilated, indicating active labor. Position changes can help progress labor by promoting fetal descent and rotation. Administering pain medication (A) may not be necessary at this point as contractions are mild. Epidural anesthesia (C) may be considered later if requested by the patient. Cesarean section (D) is not indicated at this stage unless there are specific complications.