What should the nurse do if the fetal heart rate is 152 bpm?

Correct Answer: A

Rationale: A fetal heart rate of 152 bpm falls within the normal range for a healthy fetus. The normal fetal heart rate typically ranges from 120 to 160 bpm. Therefore, choice A is the correct answer because the nurse should document this finding as a normal result. Choice B, assessing every 5 minutes, is unnecessary in this situation as a heart rate of 152 bpm is considered normal. Assessing every 5 minutes would be excessive and potentially cause unnecessary stress to the mother. Choice C, reporting to the health care practitioner, is not necessary for a normal fetal heart rate of 152 bpm. It is within the normal range and does not require any further intervention or consultation with the healthcare provider. Choice D, instituting emergency measures, is not appropriate for a fetal heart rate of 152 bpm. Emergency measures are only necessary in situations where there is a significant deviation from the normal fetal heart rate range, such as bradycardia (heart rate <120 bpm) or tachycardia (heart rate >160 bpm). In conclusion, the nurse should document a fetal heart rate of 152 bpm as a normal finding and continue to monitor the fetus for any changes or deviations from the normal range.

Correct Answer: A

Rationale: A doula's primary role is to provide physical, emotional, and informational support to pregnant individuals before, during, and after childbirth. Giving a back massage is an appropriate action for a doula because it can help alleviate discomfort, reduce stress, and promote relaxation during labor. This physical support can also help the individual cope with contractions and promote a sense of well-being. Assessing fetal heart rate (Choice B) is typically the responsibility of a healthcare provider, such as a midwife or obstetrician. This task requires specialized training and equipment to accurately monitor the baby's well-being during labor. Doulas are not qualified to interpret fetal heart rate patterns and should not attempt to do so. Assessing blood pressure (Choice C) is also a task that falls within the scope of practice of healthcare providers. Monitoring blood pressure is crucial for assessing the individual's overall health and detecting any potential complications during labor. Doulas do not have the training or equipment required to accurately measure blood pressure. Regulating IV (Choice D) involves administering intravenous fluids, medications, or other substances to support the individual during labor. This task should only be performed by trained medical professionals, such as nurses or doctors, who have the necessary knowledge and skills to safely manage IV therapy. Doulas do not have the qualifications to regulate IVs and should not attempt to do so. In conclusion, giving a back massage is an appropriate action for a doula because it aligns with their role of providing physical comfort and support during labor. Assessing fetal heart rate, blood pressure, and regulating IVs are tasks that should be left to healthcare professionals with the appropriate training and expertise.

Correct Answer: B

Rationale: If a client reports seeing blood-tinged mucus, the nurse's first priority should be to acknowledge the client's concerns (choice B). This is important because it shows empathy and validates the client's feelings, which can help establish trust and rapport. It also allows the nurse to gather more information from the client about the situation, such as how long it has been happening and if there are any other symptoms present. Assessing for a urinary tract infection (choice A) may be necessary at some point, but it is not the first step. The client's emotional well-being and concerns should be addressed before moving on to a physical assessment. Explaining that it is normal (choice C) may not be accurate and could potentially cause the client further distress. It is important for the nurse to gather more information and assess the situation before making any assumptions. Clarifying that it is not actual bleeding (choice D) may also be necessary, but it should not be the first action taken. The client's concerns should be acknowledged and addressed before providing any information or reassurance.

Correct Answer: A

Rationale: The correct sequence of cardinal moves of labor is internal rotation, extension, external rotation (Choice A). First, internal rotation is when the baby's head rotates to face the mother's back in order to navigate through the pelvis more easily. This is followed by extension, where the baby's head is able to pass under the pubic bone. Finally, external rotation occurs as the baby's head rotates back to its original position to facilitate delivery. Choice B (Descent, extension, external rotation) is incorrect because descent is not one of the cardinal moves of labor. Descent refers to the movement of the baby's head through the birth canal, but it is not a specific cardinal move in the sequence. Choice C (Flexion, internal rotation, extension) is incorrect because flexion, or the baby tucking their chin to their chest, is not one of the cardinal moves of labor. While flexion can occur during labor, it is not part of the specific sequence of cardinal moves. Choice D (Internal rotation, external rotation, expulsion) is incorrect because it skips the crucial step of extension, which is necessary for the baby to pass through the birth canal. Without extension, the baby's head cannot navigate under the pubic bone for delivery. In conclusion, the correct sequence of cardinal moves of labor is internal rotation, extension, external rotation, making Choice A the correct answer.

Correct Answer: C

Rationale: The correct answer is C: Flexed. When a fetus is in a flexed position, it means that the head is bent towards the chest, which is also known as the chin-on-chest position. This position is considered the optimal fetal attitude for vaginal delivery as it allows for easier passage through the birth canal. Choice A: Extended is incorrect because an extended fetal attitude refers to the head being in a position where it is tilted back, away from the chest. This position can make it more difficult for the baby to pass through the birth canal during delivery. Choice B: Neutral is incorrect because a neutral fetal attitude indicates that the baby's head is in a straight, neutral position with neither flexion nor extension. This position is less common and may not be ideal for vaginal delivery. Choice D: Variable is incorrect because a variable fetal attitude means that the baby's head can be in various positions, including flexed, extended, or neutral. This position can make it difficult to predict the optimal position for delivery and may increase the risk of complications during childbirth. In summary, the correct answer is C: Flexed because it represents the chin-on-chest position, which is the ideal fetal attitude for vaginal delivery. Choices A, B, and D are incorrect because they do not describe the specific position of the fetus's head in relation to the chest during childbirth.