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Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth?
- A. Bloody mucous discharge increases.
- B. The vulva bulges and encircles the fetal hea
- C. The fetal head is felt at 0 station during the vaginal examination.
- D. The membranes rupture during a contraction.
Correct Answer: B
Rationale: The correct answer is B because the vulva bulging and encircling the fetal head is a sign that the baby is descending through the birth canal, indicating the patient is almost ready to give birth. This is known as crowning.
A: Bloody mucous discharge increasing is a sign of early labor, not necessarily indicating imminent birth.
C: Feeling the fetal head at 0 station means the baby is engaged in the pelvis, but it does not indicate the exact timing of birth.
D: Membranes rupturing during a contraction can happen at any stage of labor and do not necessarily signify imminent birth.
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Which of the following describes the purpose of Leopold's maneuvers?
- A. To assess cervical dilation and effacement.
- B. To determine fetal presentation and position.
- C. To measure the frequency of contractions.
- D. To estimate the weight of the fetus.
Correct Answer: B
Rationale: The purpose of Leopold's maneuvers is to determine the fetal presentation and position. Step 1 assesses the fundal height and shape, indicating the fetal part. Step 2 locates the back or limbs. Step 3 determines the presenting part in the pelvis. Step 4 confirms the presenting part and its mobility. This method helps in identifying the optimal fetal position for delivery. Assessing cervical dilation and effacement (Choice A) is typically done through vaginal examination. Measuring the frequency of contractions (Choice C) and estimating the weight of the fetus (Choice D) are not objectives of Leopold's maneuvers.
A patient is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or perform procedures?
- A. After the contraction is over
- B. When it is all right with the coach
- C. During the increment of the next contraction
- D. After administration of analgesic-anesthetic
Correct Answer: C
Rationale: The correct answer is C: During the increment of the next contraction. This is the best time for assessment as the patient is likely to be more focused and cooperative during this phase. Asking questions or performing procedures during the contraction or immediately after may be distracting or uncomfortable for the patient. Waiting until the contraction is over (choice A) may delay necessary assessment. Waiting for the coach's approval (choice B) may not always align with the patient's needs. Waiting until after administration of analgesic-anesthetic (choice D) may not be timely for necessary assessment and may also impact the patient's ability to provide accurate information.
Which intervention is an essential part of nursing care for a laboring patient?
- A. Helping the woman manage the pain
- B. Eliminating the pain associated with labor
- C. Feeling comfortable with the predictable nature of intrapartal care
- D. Sharing personal experiences regarding labor and birth to decrease her anxiety
Correct Answer: A
Rationale: The correct answer is A because helping the woman manage the pain is essential in nursing care for a laboring patient to ensure her comfort and well-being during labor. This intervention includes providing pain relief measures, such as positioning, massage, breathing techniques, and administering pain medication if needed. The focus is on supporting the woman's coping mechanisms and enhancing her overall birthing experience.
Choice B is incorrect because eliminating pain completely is not always possible or recommended in labor, as some pain is a natural part of the process. Choice C is incorrect as comfort with the predictable nature of care is not as crucial as providing active pain management. Choice D is incorrect because sharing personal experiences may not be relevant or helpful to the laboring patient and may not address her specific needs during labor.
If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to
- A. massage the fundus.
- B. take the blood pressure
- C. increase blood supply to the hands and feet.
- D. notify the physician or nurse-midwif
Correct Answer: A
Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.
The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's most respectful approach for this patient?
- A. Ask the patient's labor coach if this is a usual expression of pain for her.
- B. Refer to the patient's chart to determine any orders for pain medication.
- C. Tell the patient that she is disturbing the other laboring patients on the unit.
- D. Encourage the patient to try to suppress her noisiness during contractions.
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Asking the patient's labor coach shows respect for the patient's support person and acknowledges their insight into the patient's usual behavior.
2. It allows the nurse to gather information about the patient's pain expression without assuming or judging the situation.
3. This approach promotes patient-centered care and involves the patient's primary support system in decision-making.
4. It fosters open communication and partnership between the nurse, patient, and labor coach, enhancing the overall quality of care.
Summary:
- Option B is incorrect because pain medication should not be assumed without assessing the patient's current pain level first.
- Option C is incorrect as it lacks empathy and disregards the patient's emotional state during labor.
- Option D is incorrect as it suggests suppressing a natural response to pain, which may not be beneficial for the patient's coping mechanism.