When is the placenta diagnosed as retained?

Correct Answer: B

Rationale: The placenta is considered retained when it has not been delivered within 30 minutes after the birth of the baby. This is because the placenta should ideally be delivered within this time frame to prevent any complications such as excessive bleeding or infection for the mother. Choice A: 10 minutes is too short of a time frame to diagnose the placenta as retained. It is normal for the placenta to take some time to be delivered after the baby is born, so 10 minutes would be premature to consider it retained. Choice C: 1 hour is too long of a time frame to diagnose the placenta as retained. Waiting for an hour could lead to potential complications for the mother if the placenta is indeed retained, as it should ideally be delivered within 30 minutes. Choice D: 2 hours is also too long of a time frame to diagnose the placenta as retained. Waiting for 2 hours could put the mother at risk for complications associated with a retained placenta, so it is not the correct answer. In conclusion, the correct answer is B (30 minutes) because it is the appropriate time frame within which the placenta should be delivered to prevent any potential complications for the mother.

Correct Answer: B

Rationale: Restlessness, cyanosis, and nasal flaring are all signs that indicate an alteration in oxygenation, making option B the correct answer. Restlessness is a common symptom seen in individuals who are experiencing difficulty breathing or low oxygen levels in their blood. Cyanosis, on the other hand, is a bluish discoloration of the skin and mucous membranes that occurs when there is inadequate oxygenation of the blood. It is a clear indication that the body is not receiving enough oxygen. Nasal flaring, where the nostrils widen during breathing, is a compensatory mechanism used by the body to try to increase airflow and oxygen intake. Option A, liver failure, is incorrect because restlessness, cyanosis, and nasal flaring are not typical signs or symptoms associated with liver failure. Liver failure is more commonly linked to symptoms such as jaundice, abdominal pain, and swelling in the legs and abdomen. Option C, preeclampsia, is also incorrect because while preeclampsia can cause high blood pressure and protein in the urine during pregnancy, it does not typically present with restlessness, cyanosis, or nasal flaring as primary symptoms. Preeclampsia is more commonly associated with symptoms such as headaches, blurred vision, and upper abdominal pain. Option D, gestational diabetes, is also an incorrect choice as restlessness, cyanosis, and nasal flaring are not indicative of gestational diabetes. Gestational diabetes is a condition characterized by high blood sugar levels during pregnancy and is often associated with symptoms such as excessive thirst, frequent urination, and fatigue. In conclusion, the presence of restlessness, cyanosis, and nasal flaring is a clear indication of an alteration in oxygenation, making option B the correct choice in this scenario.

Correct Answer: D

Rationale: Vaginal examination provides the most valuable information regarding the client's labor status because it allows healthcare providers to assess cervical dilation, effacement, and station of the fetus in the birth canal. These factors are crucial in determining the progress of labor and whether the client is in active labor or not. Leopold's maneuvers (Choice A) are a series of four movements used to assess the position of the fetus in the uterus. While this assessment can provide valuable information about fetal position, it does not provide direct information about the client's labor status. Fundal contractility (Choice B) refers to the strength and frequency of contractions of the uterus. While monitoring fundal contractility is important during labor, it does not provide information about cervical dilation or the position of the fetus, which are key indicators of labor progress. Fetal heart assessment (Choice C) is important for monitoring the well-being of the fetus during labor. However, it does not provide direct information about the client's labor status in terms of cervical dilation and fetal position. It is more focused on the fetal response to labor rather than the progress of labor itself. In conclusion, vaginal examination is the most valuable assessment for determining the client's labor status as it provides direct information about cervical dilation, effacement, and fetal station, which are critical indicators of labor progress.

Correct Answer: D

Rationale: During the latent phase of labor, it is crucial for the nurse to monitor the fetal heart pattern regularly to ensure the well-being of the baby. Option A, assessing the fetal heart pattern after vaginal exams, is incorrect because these exams can temporarily affect the fetal heart rate due to stimulation of the cervix or manipulation of the uterus. This can lead to inaccurate results and unnecessary concern. Option B, assessing the fetal heart pattern before administration of analgesics, is also incorrect because analgesics can cross the placenta and potentially affect the baby's heart rate. Therefore, it is important to establish a baseline fetal heart rate before administering any medications to accurately monitor changes. Option C, assessing the fetal heart pattern periodically at the end of a contraction, is incorrect because it is essential to monitor the fetal heart rate continuously throughout the contraction to identify any signs of distress or changes in the pattern that may indicate fetal compromise. Waiting until the end of a contraction may delay intervention and compromise the baby's well-being. Option D, assessing the fetal heart pattern every ten minutes, is the correct answer because it allows for frequent and consistent monitoring of the baby's heart rate to detect any changes or abnormalities promptly. This interval is recommended during the latent phase of labor when the baby is more susceptible to stress due to the length of labor and potential complications. Regular monitoring ensures timely intervention if needed, promoting the best possible outcome for both the mother and the baby.

Correct Answer: B

Rationale: When assessing the fetal position, it is crucial to understand the station, which refers to the level of the presenting part in relation to the ischial spines. In this scenario, the fetal buttocks are at 1 cm above the ischial spines. Choice A: LOA -1 station LOA stands for Left Occiput Anterior, which is a different fetal position than the buttocks presenting. Additionally, -1 station indicates that the presenting part is 1 cm above the ischial spines, not consistent with the given scenario. Choice C: LMP -1 station LMP stands for Last Menstrual Period, which is not relevant to the assessment of fetal position. Furthermore, -1 station is incorrect as it does not match the location of the fetal buttocks described in the question. Choice D: LSA -1 station LSA is not a recognized fetal position abbreviation. Additionally, -1 station does not align with the fetal buttocks being at 1 cm above the ischial spines. Therefore, choice B: LSP -1 station is the correct answer. LSP refers to Left Sacrum Posterior, which indicates that the fetus is in the breech position with the sacrum presenting. -1 station matches the description of the fetal buttocks being 1 cm above the ischial spines, making this choice consistent with the assessment.