Nokea
Which clinical finding should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)
- A. A gush of blood appears.
- B. The uterus rises upward in the abdomen.
- C. The fundus descends below the umbilicus.
- D. The cord descends further from the vagin
Correct Answer: C
Rationale: A. A gush of blood appears: This clinical finding is indicative of the placenta detaching from the uterine wall and the subsequent expulsion. The sudden release of a significant amount of blood is expected as the placenta separates.
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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.
The nurse is caring for a patient during induction of labor. The oxytocin is currently infusing at 6 mU/min. The fetal heart tracing displays a 130 baseline, moderate variability, and no accelerations or decelerations. Uterine contractions have been every 2 minutes for the last 30 minutes. What is the nurse’s next best action?
- A. Reduce the oxytocin infusion to 3 mU/min
- B. Delay the next scheduled oxytocin increase
- C. Maintain infusion at 6 mU/min
- D. Discontinue the oxytocin infusion
Correct Answer: C
Rationale: The fetal heart rate (FHR) is stable, with moderate variability and no decelerations, indicating that the fetus is not in distress. The contractions are occurring at appropriate intervals, so the nurse should maintain the current oxytocin infusion to continue labor progression.
Cephalohematoma occurring from an operative vaginal delivery increased a newborn’s risk of developing which of the following complications?
- A. Bulging fontanels
- B. Developmental delays
- C. Jaundice
- D. Macrocephaly
Correct Answer: C
Rationale: Cephalohematomas are a common complication from operative vaginal deliveries. The accumulation of blood between the infant's skull and periosteum increases the risk of jaundice because of the breakdown of red blood cells, which can overwhelm the infant's immature liver and lead to hyperbilirubinemia.
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.
A fetus is positioned in the occiput anterior position. The nurse determines that the fetus is positioned in which way?
- A. The fetal shoulder is closest to the vaginal opening.
- B. The fetal head is closest to the vaginal opening and the occiput is directed toward the maternal symphysis.
- C. The fetal head is closest to the uterine fundus and is directed toward the maternal symphysis.
- D. The fetal head is closest to the vaginal opening and is directed toward the maternal sacrum.
Correct Answer: B
Rationale: The occiput anterior position means the fetal head is closest to the vaginal opening, and the occiput is directed toward the maternal symphysis.