The nurse is caring for a patient during the first stage of labor. What is an abnormal finding?

Correct Answer: C

Rationale: The correct answer is C because a blood pressure of 142/88 is considered abnormal during the first stage of labor. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate medical attention. A: Patient moaning with contractions is a common response to pain during labor and not necessarily abnormal. B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor. D: Respiratory rate of 22 is within the normal range and not indicative of any abnormalities during labor. In summary, the abnormal finding in this scenario is the elevated blood pressure, which can be a sign of a serious condition like preeclampsia.

Correct Answer: B

Rationale: The correct answer is B because in the fourth stage of labor, immediate postpartum bonding between parents and newborn is crucial. The nurse should respect the rapid psychologic changes by taking cues from the parents on how they want this bonding experience to unfold. This approach ensures that the parents are supported in establishing a strong emotional bond with their newborn, promoting a positive postpartum experience. Choice A is incorrect because inviting the family in may not align with the parents' wishes for privacy during this intimate moment. Choice C is incorrect as asking multiple questions about taking pictures may be intrusive and disrupt the bonding process. Choice D is incorrect as separating the newborn from the parents can hinder bonding and may not align with current best practices in postpartum care.

Correct Answer: B

Rationale: The correct answer is B, asking all family members to leave the room. This is important to provide privacy, reduce distractions, and maintain the laboring person's comfort and focus. Educating the family on pain normalcy (A) is secondary to the laboring person's immediate needs. Suggesting an epidural (C) without the laboring person's consent is inappropriate. Assuming the laboring person wants the family in the room (D) disregards the individual's preferences and comfort.

Correct Answer: D

Rationale: Rationale for Correct Answer (D): - During uterine contractions, placental blood flow may be temporarily reduced but not completely halted. - Fetal-maternal exchange of oxygen and waste products continues to occur even during contractions. - This is because the placenta acts as a continuous filter, allowing exchange to happen unless placental functions are severely compromised. Summary of Other Choices: A: Incorrect. There is an effect on maternal-fetal exchange during contractions. B: Incorrect. Increased blood pressure does not necessarily correlate with increased exchange. C: Incorrect. Compression of spiral arteries may impact blood flow but does not completely stop exchange.

Correct Answer: B

Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part (usually the biparietal diameter of the fetal head) passes through the pelvic inlet. This marks the beginning of the descent of the fetal head into the pelvis in preparation for birth. Extension (A) refers to the movement of the fetal head as it passes through the birth canal. Internal rotation (C) is the movement of the fetal head to align with the maternal pelvis. External rotation (D) occurs as the fetal head exits the birth canal.