1.
During the period of induction of labor. a client should be observed carefully for signs of:
Correct Answer
B. Uterine tetany
Explanation
During the period of induction of labor, it is important to observe the client carefully for signs of uterine tetany. Uterine tetany refers to a sustained contraction of the uterus that lasts longer than 2 minutes, causing a decrease in blood flow to the placenta and potentially compromising fetal well-being. This condition can be identified by monitoring the frequency, duration, and intensity of contractions. Prompt recognition and intervention are crucial to prevent further complications and ensure a safe delivery for both the mother and baby.
2.
A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning. the client is bearing down. and the birth appears imminent. The nurse should:
Correct Answer
D. Support the perineum with the hand to prevent tearing and tell the client to pant
Explanation
In the second stage of labor, when the fetus's head is crowning and the birth appears imminent, the nurse should support the perineum with the hand to prevent tearing. This is important as it helps to protect the perineal area and reduce the risk of injury during delivery. Additionally, the nurse should instruct the client to pant during contractions and breathe through her mouth. Panting helps to slow down the pushing and prevent rapid delivery, allowing for controlled and gradual birth of the baby.
3.
A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she:
Correct Answer
A. Will not feel the episiotomy
Explanation
Once the pudendal block is working, the client will not feel the episiotomy. A pudendal block is a type of regional anesthesia that numbs the perineum, which includes the area around the vagina and rectum. This block is commonly used during childbirth to provide pain relief during the delivery of the baby and any necessary episiotomy. By blocking the nerves in the perineum, the client will not feel the incision made during an episiotomy.
4.
Which of the following observations indicates fetal distress?
Correct Answer
A. Fetal scalp pH of 7.14
Explanation
A fetal scalp pH of 7.14 indicates fetal distress. This is because a normal fetal scalp pH is between 7.25 and 7.35, and a pH lower than 7.20 suggests fetal acidemia, which is a sign of distress. Fetal acidemia can occur when there is a decrease in oxygen supply to the fetus, leading to metabolic acidosis. This can be caused by various factors such as placental insufficiency, umbilical cord compression, or maternal hypotension. Monitoring fetal scalp pH is an important tool in assessing fetal well-being and detecting distress during labor.
5.
Which of the following fetal positions is most favorable for birth?
Correct Answer
A. Vertex presentation
Explanation
Vertex presentation is the most favorable fetal position for birth because it means that the baby's head is positioned to come out first through the birth canal. This is the most common and safest position for delivery as it allows for an easier passage through the pelvis. The head is able to apply pressure on the cervix, helping it to dilate and facilitate a smooth delivery.
6.
A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor?
Correct Answer
D. Oxygenation
Explanation
By examining the fetal heart rate strip produced by the external electronic fetal monitor, one can determine the oxygenation status of the fetus. The fetal heart rate pattern can provide valuable information about the oxygen supply to the fetus. A normal heart rate pattern indicates good oxygenation, while abnormal patterns may suggest fetal distress and compromised oxygenation. Monitoring the fetal heart rate strip helps healthcare providers assess the well-being of the fetus during labor and make appropriate interventions if necessary.
7.
A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?
Correct Answer
C. Active pHase
Explanation
During the active phase of the first stage of labor, cervical dilation occurs most rapidly. This phase is characterized by strong and regular contractions that help to further dilate the cervix. The active phase typically begins when the cervix is around 4-6 cm dilated and continues until it reaches 10 cm. The contractions during this phase become more intense and frequent, allowing for faster dilation of the cervix. This is the phase where the laboring client is likely to experience the most progress in terms of cervical dilation.
8.
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?
Correct Answer
C. Perform a pelvic examination
Explanation
In this scenario, the client's statement of feeling the urge to move her bowels could indicate that she is experiencing the urge to push, which is a sign of advanced labor. Therefore, the nurse should perform a pelvic examination to assess the progress of labor and determine if the client is ready to push. This will help the nurse to provide appropriate care and support during the delivery process.
9.
Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?
Correct Answer
C. Passageway. contractions. placental position. and function. psychological response
Explanation
The correct answer is Passageway, contractions, placental position, and function, and psychological response. These four factors, along with the passenger (fetus), are essential in determining the progress and outcome of labor. The passageway refers to the birth canal and its adequacy for the passage of the fetus. Contractions are the rhythmic tightening and relaxation of the uterus that help to push the fetus through the birth canal. The position and function of the placenta are important for the supply of oxygen and nutrients to the fetus. Lastly, the psychological response of the mother can affect the progress of labor, as stress and anxiety can interfere with the natural process.
10.
Fetal presentation refers to which of the following descriptions?
Correct Answer
A. Fetal body part that enters the maternal pelvis first
Explanation
Fetal presentation refers to the fetal body part that enters the maternal pelvis first during childbirth. This is an important factor in determining the progress and outcome of labor. The presentation can be classified into different categories based on which body part is leading, such as cephalic (head first), breech (buttocks first), or shoulder presentation. Understanding the fetal presentation helps healthcare providers to plan and manage the delivery process effectively.