Nokea
Why should the nurse encourage the mother to void during the fourth stage of labor?
- A. A full bladder could interfere with cervical dilation.
- B. A full bladder could obstruct progress of the infant through the birth canal.
- C. A full bladder could obstruct the passage of the placenta.
- D. A full bladder could predispose the mother to uterine hemorrhage.
Correct Answer: D
Rationale: A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.
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The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient?
- A. By offering the patient warm fluids to drink
- B. By helping the patient to ambulate in the room
- C. By seating the patient upright in a straight-back chair
- D. By positioning the patient on her right side
Correct Answer: B
Rationale: Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. How would the nurse record this presentation?
- A. Complete breech
- B. Frank breech
- C. Double footing
- D. Buttocks presentation
Correct Answer: B
Rationale: When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.
What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?
- A. Fetal distress
- B. Fetal maturity
- C. Intact gastrointestinal tract
- D. Dehydration in the mother
Correct Answer: A
Rationale: Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.
What is the most important nursing intervention during the fourth stage of labor?
- A. Monitor the frequency and intensity of contractions.
- B. Provide comfort measures.
- C. Assess for hemorrhage.
- D. Promote bonding.
Correct Answer: C
Rationale: Immediately after giving birth, every woman is assessed for signs of hemorrhage.
What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push?
- A. At the beginning of a contraction, hold your breath and push for 10 seconds.'
- B. Take a deep breath and push between contractions.'
- C. Begin pushing when a contraction starts and continue for the duration of the contraction.'
- D. At the beginning of a contraction, take two deep breaths and push with the second exhalation.'
Correct Answer: D
Rationale: When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.