Question 1

The nurse is caring for a laboring patient. A cervical exam indicates 8 cm dilation. The patient is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important?

A)Leave the patient alone so she can rest.
B)Ask the family to take a coffee and snack break.
C)Encourage the patient to have an epidural for pain.
D)Reassure the patient that she will not be left alone.

Accepted Answer

The patient is restless and changing positions frequently, indicating discomfort and possibly anxiety. It is important to reassure the patient that she will not be left alone, as this can reduce anxiety and provide support for the patient during labor. Leaving the patient alone, asking the family to take a break, or encouraging an epidural may not address the patient's immediate need for comfort and reassurance.

Question 2

During the fourth stage of labor, your patient's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse should be to:

A)Turn the patient onto her left side.
B)Place the bed in Trendelenburg position.
C)Massage the fundus.
D)Continue to monitor.

Continue to monitor.

Accepted Answer

The priority action for the nurse during the fourth stage of labor with the given assessment is to continue to monitor the patient's vital signs and fundus. The patient's blood pressure, pulse, and firm midline fundus indicate that the patient is stable and does not require immediate intervention. Massage of the fundus may be necessary if the fundus becomes boggy, but this is not indicated in the given assessment. Turning the patient onto her left side or placing the bed in Trendelenburg position may be appropriate actions in certain situations, but they are not indicated in the given assessment.

Question 3

The primiparous patient at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?&#10;A)&#34;Unless you have pain with urination, we don't need to worry about it.&#34;&#10;B)&#34;These symptoms usually mean the baby's head has descended further.&#34;&#10;C)&#34;Come in for an appointment today and we'll check everything out.&#34;&#10;D)&#34;This might indicate that the baby is no longer in a head down position.&#34;

Accepted Answer

Increased pelvic pressure and increased urinary frequency are common signs that the baby's head has descended further down into the pelvis in preparation for labor. This is a normal part of the third trimester and does not necessarily indicate any problems. However, it is always a good idea to monitor these symptoms and schedule an appointment with the healthcare provider if there are any concerns. Option A is incorrect because pain is not necessarily the only indicator of a problem. Option C is an appropriate response but may not be necessary unless the patient has other symptoms or concerns. Option D may or may not be true, but it is not the most likely explanation for the patient's symptoms.

Question 4

Which patient requires immediate intervention by the labor and delivery nurse?&#10;A)Multip at 8 cm, systolic blood pressure has increased 35 mm Hg&#10;B)Primip that delivered one hour ago with WBC of 50,000&#10;C)Multip at 5 cm with a respiratory rate of 22 between contractions&#10;D)Primip in active labor with urine output of 100 ml/hour

Accepted Answer

A WBC count of 50,000 indicates a potential infection and requires immediate intervention by the labor and delivery nurse. The other options may require monitoring or interventions, but are not immediate emergencies.

Question 5

A healthy 18-year-old patient who is 40 weeks' gestation presents at the clinic complaining of vaginal expulsion of stringy mucus followed by blood-tinged secretions. She denies any discomfort or any other changes. Based upon the patient's complaints, what is most likely to occur within the next 24 to 48 hours?

A)Onset of labor
B)Spontaneous abortion
C)Cesarean section
D)Chorioamnionitis

Accepted Answer

The expulsion of stringy mucus followed by blood-tinged secretions is likely the mucus plug and is a sign of cervical ripening and impending labor. This is a normal process that occurs as the cervix softens and prepares for delivery. Spontaneous abortion or chorioamnionitis are not indicated by the patient's presentation, and cesarean section would not be necessary based solely on this complaint.

Question 6

The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor?

A)Increased pulse
B)Elevated blood pressure
C)Muscle tension
D)Increased respirations

Accepted Answer

Muscle tension can impede progress in labor as it can cause the woman to resist the natural uterine contractions needed to progress labor. Increased pulse, elevated blood pressure, and increased respirations are all normal physiological responses to pain and do not necessarily impede progress in labor.

Question 7

The nurse is caring for laboring patients. Which women are experiencing problems related to a critical factor of labor?&#10;A)Primip at 7 cm, fetus in military attitude&#10;B)Multip at 3 cm, fetus in longitudinal lie&#10;C)Primip at 4 cm, fetus with macrocephaly due to hydrocephalus&#10;D)Multip at 6 cm, fetus at &#8722;2 station, mild contractions&#10;E)Primip at 5 cm, fetal presenting part is right shoulder

Accepted Answer

The answer of The nurse is caring for laboring patients....

Question 8

The primiparous patient at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make?

A)"You shouldn't work so much at this point in pregnancy."
B)"What you are describing is not commonly experienced in the last weeks."
C)"Your body may be telling you it is going into labor soon."
D)"If the bladder pressure continues, come in to the clinic tomorrow."

Accepted Answer

The nurse should educate the patient that the symptoms she is experiencing may indicate that her body is preparing for labor. With increased bladder pressure and mild contractions, it is possible that the patient is beginning to dilate and efface. The patient's nesting behavior by cleaning the entire house could also be a sign that labor is imminent. It is important for the patient to be aware of these signs and symptoms and to contact the clinic if there are any concerns or if the contractions become more regular or intense. Option A is not a helpful response, as it does not address the patient's concerns or provide any guidance. Option B is incorrect, as the symptoms described are commonly experienced in the last weeks of pregnancy. Option D is not the best choice, as bladder pressure is a common symptom at this stage of pregnancy, and waiting until tomorrow to come in to the clinic may delay any necessary interventions.

Question 9

A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are two minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure. How should the nurse interpret this complaint?

A)The patient's complaint is congruent with her current stage of labor.
B)The patient's complaint may indicate the need for delivery via cesarean section.
C)Based upon the patient's complaint, she is experiencing the active phase of labor.
D)The patient's complaint is consistent with placental separation, which is normal for her current stage of labor.

Accepted Answer

Excruciating rectal pressure is a common complaint during the second stage of labor when the baby's head begins to descend down the birth canal and put pressure on the rectum. In this case, the patient is demonstrating cervical dilatation of 9 cm, indicating that she is in the second stage of labor. Additionally, her contractions are close together and of sufficient duration, further supporting the diagnosis of the second stage of labor. Therefore, the nurse should interpret the patient's complaint as congruent with her current stage of labor.

Question 10

While caring for a labor patient, the nurse determines during a vaginal exam that the baby's head has internally rotated. This information is given to the family. The labor support person asks the nurse, "What other position changes will the baby undertake during labor and birth?" How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation?

A)Flexion, extension, restitution, external rotation, and expulsion
B)Expulsion, external rotation, and restitution
C)Restitution, flexion, external rotation, and expulsion
D)Extension, restitution, external rotation, and expulsion

Accepted Answer

The answer of While caring for a labor patient, the...

Deck 17: Processes and Stages of Labor and Birth