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 high and abnormal during the first stage of labor. This could indicate hypertension, which can have serious implications for both the mother and the baby. High blood pressure can lead to complications such as preeclampsia. A, B, and D are incorrect because: A: Patient moaning with contractions is a common response to labor pains and does not necessarily indicate an abnormal finding. B: Contractions 3 minutes apart lasting 60 seconds are within the normal range for the first stage of labor. D: A respiratory rate of 22 is also within the normal range and is not indicative of any abnormal findings during the first stage of labor.

Correct Answer: B

Rationale: The correct answer is B. In the fourth stage of labor, the nurse should respect the rapid psychologic changes by taking the lead from the parents regarding interruption of bonding. This is important because it allows the parents to establish a strong bond with their newborn without feeling pressured or rushed. By following the parents' cues, the nurse can support their emotional needs and facilitate a positive bonding experience. Choices A, C, and D are incorrect because they do not prioritize the parents' emotional needs and may disrupt the bonding process. Inviting the family to see the newborn (Choice A) may add stress to the situation. Asking multiple questions about taking pictures (Choice C) may be intrusive. Taking the newborn to the nursery (Choice D) may interfere with the bonding process and discourage parental involvement.

Correct Answer: B

Rationale: The correct answer is B because having multiple family members in the room during labor can be overwhelming and hinder the progress of labor. It is important for the laboring person to have privacy, focus, and reduce stress for a smoother labor experience. Asking the family members to leave the room ensures a calm and supportive environment for the laboring person. Incorrect Choices: A: Educating the family about pain normalcy is helpful, but privacy and focus are more crucial during labor. C: Mentioning epidural may not be appropriate as it is the laboring person's decision and may not be the best option for everyone. D: Assuming the laboring person wants family in the room without considering their preference may not be the best approach for their comfort and progress in labor.

Correct Answer: D

Rationale: The correct answer is D because maternal-fetal exchange of oxygen and waste products continues during uterine contractions unless placental functions are reduced. Contractions do not directly affect this exchange, so option A is incorrect. Option B is incorrect because blood pressure changes do not necessarily impact the exchange. Option C is incorrect because spiral arteries play a role in supplying blood to the placenta, but compression during contractions does not halt the exchange process.

Correct Answer: B

Rationale: The correct answer is B: Engagement. Engagement occurs when the largest diameter of the fetal presenting part passes through the pelvic inlet, indicating the descent of the fetal head into the pelvis. This is a crucial step in labor progress as it signifies the baby's readiness for birth. A: Extension occurs during the second stage of labor when the baby's head passes through the birth canal. C: Internal rotation is the movement of the baby's head within the pelvis to align with the maternal pelvis. D: External rotation happens after the baby's head is delivered to allow for the shoulders to rotate for birth. In summary, engagement is the correct answer as it specifically refers to the largest diameter of the fetal presenting part passing the pelvic inlet, setting the stage for the progression of labor.