Nokea
Which physiologic event is the key indicator of the commencement of true labor?
- A. Bloody show
- B. Cervical dilation and effacement
- C. Fetal descent into the pelvic inlet
- D. Uterine contractions every 7 minutes
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation and effacement. This is the key indicator of true labor as it signifies the physiological changes needed for the cervix to open and thin out, allowing the baby to pass through the birth canal. Bloody show (A) can be present in early labor but is not a definitive sign. Fetal descent (C) and regular uterine contractions (D) are important, but cervical changes are the most reliable indicator of true labor initiation.
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The nurse is caring for a laboring patient with multiple family members in the room. How can the nurse address this situation?
- A. Educate the family that the pain the laboring person is experiencing is normal.
- B. Ask them all to leave the room.
- C. Explain that if the laboring person got an epidural, she would be more comfortable
- D. Assume the laboring person wants the family in the room
Correct Answer: B
Rationale: The correct answer is B because having multiple family members in the room during labor can be overwhelming and hinder the progress of labor. It is important for the laboring person to have privacy, focus, and reduce stress for a smoother labor experience. Asking the family members to leave the room ensures a calm and supportive environment for the laboring person.
Incorrect Choices:
A: Educating the family about pain normalcy is helpful, but privacy and focus are more crucial during labor.
C: Mentioning epidural may not be appropriate as it is the laboring person's decision and may not be the best option for everyone.
D: Assuming the laboring person wants family in the room without considering their preference may not be the best approach for their comfort and progress in labor.
A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
- A. The biparietal diameter of the fetal head is at the level of the ischial spines.
- B. The biparietal diameter of the fetal head is at –2 station.
- C. The fetal head is well flexed.
- D. The fetal head is unable to pass under the pubic arch.
Correct Answer: A
Rationale: The correct answer is A: The biparietal diameter of the fetal head is at the level of the ischial spines. Engagement of the fetal head occurs when the largest transverse diameter of the presenting part (usually the biparietal diameter) reaches or passes through the pelvic inlet, specifically at the level of the ischial spines. This signifies descent of the fetal head into the maternal pelvis, indicating progress towards labor.
Choice B (The biparietal diameter of the fetal head is at –2 station) is incorrect as station refers to the level of the presenting part in relation to the ischial spines, not engagement.
Choice C (The fetal head is well flexed) is incorrect as engagement does not necessarily indicate the position of the fetal head.
Choice D (The fetal head is unable to pass under the pubic arch) is incorrect as engagement actually signifies that the fetal head is in the optimal position to pass through the pelvis during labor.
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 sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?
- A. Face presentation
- B. Breech presentation
- C. Vertex presentation
- D. Shoulder presentation
Correct Answer: A
Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) is the presenting part. The chin is the prominent part of the face, making it a face presentation. In a face presentation, the fetus is in a position where the head is extended rather than flexed. This can lead to complications during delivery.
Summary:
B: Breech presentation - In breech presentation, the baby's buttocks or feet are the presenting part.
C: Vertex presentation - In vertex presentation, the baby's head is the presenting part with the chin tucked towards the chest.
D: Shoulder presentation - In shoulder presentation, the baby is positioned transversely in the uterus with one or both shoulders presenting first.
When caring for a woman with a complete placenta previa, which finding should the nurse report to the physician?
- A. BP of 95/60
- B. Temperature of 100.1°F
- C. Urine output of 40 mL/hour
- D. O2 saturation less that 95%
Correct Answer: D
Rationale: The correct answer is D: O2 saturation less than 95%. In placenta previa, there is a risk of maternal hemorrhage, which can lead to decreased oxygen delivery to tissues. Reporting low O2 saturation is crucial as it indicates potential hypoxia, necessitating immediate intervention. Choice A (BP of 95/60) may be within normal limits. Choice B (Temperature of 100.1°F) can indicate infection but is not directly related to placenta previa. Choice C (Urine output of 40 mL/hour) may reflect renal function but is not the priority in this situation.