During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

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Question 1 of 5

During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

Correct Answer: C

Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure. A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client. B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter. D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.

Question 2 of 5

While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Correct Answer: D

Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.

Question 3 of 5

When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?

Correct Answer: C

Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.

Question 4 of 5

During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

Correct Answer: A

Rationale: The correct answer is A: Maternal fever. Maternal fever can lead to tachycardia in the fetus due to the transfer of maternal antibodies, cytokines, and other inflammatory mediators across the placenta, affecting fetal heart rate. Maternal fever can indicate infection, which can cause fetal distress. The other choices are incorrect because: B: Fetal heart failure typically presents with bradycardia, not tachycardia. C: Maternal hypoglycemia can affect the fetus but is more likely to cause fetal bradycardia than tachycardia. D: Fetal head compression can result in decelerations but not necessarily tachycardia.

Question 5 of 5

A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?

Correct Answer: A

Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress. Summary of other choices: B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring. C: Inserting an IV catheter is important but not the priority when late decelerations are observed. D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.

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