Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours post partum, PR= 80 bpm, fundus soft and boundaries not well defined. The appropriate nursing diagnosis is: Show Hemorrhage secondary to uterine atony Rationale: The following are common causes of dysfunctional labor. Which of these can a nurse, on her own manage? Full bladder Rationale: Full bladder can impede the descent of the fetal head. The nurse can readily manage this problem by doing a simple catheterization of the mother. Which of the following techniques during labor and delivery can lead to uterine inversion? Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation Rationale: When delivering the baby's head the nurse supports the mother's perineum to prevent tear. This technique is called Ritgen's technique Rationale: The following are natural childbirth procedures EXCEPT: Ritgen's maneuver Rationale: When doing perineal care in preparation for delivery, the nurse should observe the following EXCEPT Paint the inner thighs going towards the perineal area Rationale: To
ensure that the baby will breath as soon as the head is delivered, the nurse's priority action is to Suction the nose and mouth to remove mucous secretions Rationale: When the baby's head is out, the immediate action of the nurse is Check if there is cord coiled around the neck Rationale: The mechanisms involved in fetal delivery is Descent, flexion, internal rotation, extension, external rotation Rationale: When the shiny portion of the placenta comes out first, this is called the ___ mechanism. Schultze Rationale:
When determining the duration of a uterine contraction the right technique is to time it from The beginning of one contraction to the end of the same contraction Rationale: When shaving a woman in preparation for cesarean section, the area to be shaved should be from ___ to ___ Under breast to mid-thigh including the pubic area Rationale: The cervical dilatation taken at 8:00 A.M. in a G1P0 patient was 6 cm. A repeat I.E. done at 10 A.M.
showed that cervical dilation was 7 cm. The correct interpretation of this result is: The active phase of Stage 1 is protracted Rationale: The drug usually given parentally to enhance uterine contraction is: Pitocin Rationale: The common oxytocin given to enhance uterine contraction is pitocin. This is also the drug given to induce labor. The first thing that a nurse must ensure when the baby's head comes out is No part of the cord is encircling the baby's neck Rationale: The fetal heart rate is checked following rupture of the bag of waters in order to: Determine if cord compression followed the rupture Rationale: After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head. In the Philippines, if a nurse performs abortion on the mother who wants it done and she gets paid for doing it, she will be held liable because Abortion is both immoral and illegal in our country Rationale: The basic delivery set for normal vaginal delivery includes the following instruments/articles EXCEPT: Retractor Rationale: The following are correct statements about false labor EXCEPT The duration of contraction progressively lengthens over time Rationale: To monitor the frequency of the uterine contraction during labor, the right technique is to time the contraction From the beginning of one contraction to the beginning of the next contraction Rationale: At what stage of labor and delivery does a primigravida differ mainly from
a multigravida? Stage 1 Rationale: In a gravido-cardiac mother, the first 2 hours postpartum (4th stage of labor and delivery) particularly in a cesarean section is a critical period
because at this stage There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. Rationale: When
the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is: Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position Rationale: At what stage of labor is the mother advised to bear down? During a uterine contraction Rationale: As soon as the placenta is delivered, the nurse must do which of the following actions? Inspect the placenta for completeness including the membranes Rationale: In vaginal delivery done in the hospital setting, the doctor
routinely orders an oxytocin to be given to the mother parenterally. The oxytocin is usually given after the placenta has been delivered and not before because: Oxytocin can make the cervix close and thus trap the placenta inside Rationale: During an internal examination, the nurse palpated the posterior fontanel to be at the left side of the mother at the upper quadrant. The interpretation is that the position of the fetus is: LOA Rationale: The passageway in labor and deliver of the fetus include the following EXCEPT Flexibility of the pelvis Rationale: If
the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may occur: 1,2,3,4 Rationale: The normal umbilical cord is composed of: 2 arteries and 1 vein Rationale: The peak point of a uterine contraction is called the Acme Rationale: The partograph is a tool used to monitor labor. The maternal parameters measured/monitored are the following EXCEPT: Fluid intake and output Rationale: When the fetal head is at the level of the ischial spine, it is said that the station of the head is Station "0" Rationale: Which of the following conditions will lead to a small-for-gestational age fetus due to less blood supply to the fetus? Maternal cardiac condition Rationale: The
second stage of labor begins with ___ and ends with __? Begins with complete dilatation and effacement of cervix and ends with delivery of baby Rationale: Which provision of our 1987 constitution guarantees the right of the unborn child to life from conception is Article II section 12 Rationale: The normal dilatation of the cervix during the first stage of labor in a nullipara is 1.2 cm/hr Rationale: When the nurse palpates the suprapubic area of the mother and found that the presenting part is still movable, the right term for this observation that the fetus is floating Rationale: The placenta should be delivered normally within ___ minutes after the delivery of the baby. 30 minutes Rationale: The following are signs that the placenta has detached EXCEPT: Mother feels like bearing down Rationale: The primary power involved in labor and delivery is Uterine contraction Rationale: What are the important considerations that the nurse must remember after the placenta is delivered? 1 and 3 Rationale: When the bag of waters ruptures, the
nurse should check the characteristic of the amniotic fluid. The normal color of amniotic fluid is Clear as water Rationale: The fetal heart beat should be monitored every
15 minutes during the 2nd stage of labor. The characteristic of a normal fetal heart rate is The heart rate will decelerate during a contraction and then go back to its pre-contraction rate after the contraction Rationale: The proper technique to monitor the intensity of a uterine contraction is Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction Rationale: The preferred manner of delivering the baby in a
gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesia. The main rationale for this is: To make the delivery effort free and the mother does not need to push with contractions Rationale: If the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may occur: 1,2,3,4 Rationale: When giving narcotic analgesics to mother in labor, the special consideration to follow is: Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Rationale: The following are types of breech presentation EXCEPT: Incomplete Rationale: Which of the following conditions will lead to a small-for-gestational age fetus due to less blood supply to the fetus? Maternal cardiac condition When determining the duration of uterine contraction the right technique is to time it from?When timing contractions, start counting from the beginning of one contraction to the beginning of the next. The easiest way to time contractions is to write down on paper the time each contraction starts and its duration, or count the seconds the actual contraction lasts, as shown in the example below.
How do you assess the duration of a contraction quizlet?When assessing the duration of labor contractions by palpation, the nurse should time from the: Beginning of one contraction to the end of the same contraction. During normal labor, contractions characteristically become: More frequent and of longer duration.
What is uterine contraction duration?The frequency of uterine contractions will be 3-5 times in every 10 minute period. Each contraction lasts 40–60 seconds; this is known as the duration of contractions.
How do you measure the intensity of uterine contractions?The intensity of the contractions can be estimated by touching the uterus. The relaxed or mildly contracted uterus usually feels about as firm as a cheek, a moderately contracted uterus feels as firm as the end of the nose, and a strongly contracted uterus is as firm as the forehead.
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When determining the duration of a uterine contraction the right technique is to time it from quizlet?
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