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Without doing a vaginal examination, a nurse concludes that a primigravida, who has received no medications during her labor, is in transition. Which of the following signs/symptoms would lead a nurse to that conclusion?
- A. The woman fell asleep during a contraction.
- B. The woman yelled at her partner and vomited.
- C. The woman laughed at something on the television.
- D. The woman began pushing with each contraction.
Correct Answer: B
Rationale: Yelling and vomiting are common signs of the transition phase of labor, characterized by intense contractions and emotional distress.
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Which finding indicates the best quality improvement process?
- A. Staff identifies the wait time in the emergency department is too long.
- B. Administration identifies the design of the facility’s lobby increases patient stress.
- C. Director of the hospital identifies the payment schedule does not pay enough for overtime.
- D. Health care providers identify the inconsistencies of some of the facility’s policy and procedures.
Correct Answer: A
Rationale: The quality improvement process begins at the staff level, where problems are defined by the staff. It is not identified by administration, the hospital director, or health care providers.
A mother, 39 weeks’ gestation, is admitted to the labor suite with rupture of membranes 15 minutes earlier and contractions q 8 minutes × 30 seconds. On vaginal exam, the cervix is 4 cm dilated and 80% effaced, and the station is –2. The baby is found to be in the LSP position. The fetal heart rate is 144 with average variability and variable decelerations. Which of the following complications of labor must the nurse assess this client for at this time?
- A. Precipitous delivery.
- B. Chorioamnionitis.
- C. Uteroplacental insufficiency.
- D. Prolapsed cord.
Correct Answer: D
Rationale: LSP (left sacrum posterior) position and rupture of membranes increase the risk of a prolapsed umbilical cord, which is a medical emergency.
The nurse is admitting a client, who reports, 'My water broke yesterday, and I haven't felt my baby move any today.' She is 38 weeks with a history of gestational diabetes. Which assessment data is of most concern to the nurse on admission?
- A. Maternal vital signs: T 100.2, HR 104, RR 20, BP 136/82
- B. Pain score 6/10
- C. Minimal variability and variable decelerations
- D. 5 cm/80% effaced/0 station
Correct Answer: C
Rationale: The correct answer is C because minimal variability and variable decelerations on fetal heart monitoring indicate fetal distress, which is a critical concern. Minimal variability suggests the baby's nervous system is compromised, and decelerations can indicate umbilical cord compression or placental insufficiency, possibly leading to fetal hypoxia. This situation requires immediate intervention to prevent potential harm to the baby.
Choice A is incorrect as the vital signs are slightly elevated but not as concerning as fetal distress. Choice B is incorrect as pain score is subjective and not as critical as fetal well-being. Choice D is incorrect as cervical dilation/effacement/station is important for labor progress but not as concerning as fetal distress in this scenario.
The mother of a neonate with Down syndrome wishes to breastfeed. Which of the following considerations should the nurse make in relation to the mother’s wishes?
- A. The mother should be encouraged to feed expressed breast milk via a bottle.
- B. Down syndrome babies consume more calories than unaffected neonates.
- C. Because of the weight of the neonatal head, the side-lying position must be used.
- D. The baby will likely have a weak suck due to congenitally poor muscle tone.
Correct Answer: D
Rationale: Babies with Down syndrome often have hypotonia, which can affect their ability to suck effectively during breastfeeding.
A pregnant patient asks the prenatal nurse how much physical activity is safe during pregnancy. What is an acceptable response by the nurse?
- A. Decreasing physical activity decreases emotional and physical symptoms.
- B. Increasing physical activity increases emotional and physical symptoms.
- C. Physical activity during pregnancy should be limited to hygiene and household tasks.
- D. The level of activity prior to pregnancy is used to determine a safe activity level during pregnancy.
Correct Answer: D
Rationale: The correct answer is D because the level of activity prior to pregnancy is a good indicator of the safe activity level during pregnancy. This is because pregnant women are generally encouraged to continue their pre-pregnancy level of exercise, adjusting as needed based on individual circumstances.
A is incorrect because decreasing physical activity may lead to more physical discomfort and emotional symptoms. B is incorrect as increasing physical activity can be beneficial if done safely. C is incorrect because hygiene and household tasks alone may not provide sufficient physical activity during pregnancy.