A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Not satisfied with the nonpharmacological comfort measures

active phase of labor

Going to require more pain medication

Going to have a long labor

Answer and Explanation

The Correct Answer is B

A. Not satisfied with the nonpharmacological comfort measures. This describes dissatisfaction with pain management but does not specifically indicate a change in labor phase.

B. Active phase of labor. Nausea, irritability, and feelings of helplessness are classic signs of transitioning from the latent phase to the active phase of labor, when contractions become stronger and more intense.

C. Going to require more pain medication: Although the patient may need additional pain relief, the question is asking about labor progression, not pain management.

D. Going to have a long labor. Irritability and nausea are signs of labor progression, not necessarily an indicator of a long labor.

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Correct Answer is C

Explanation

A. Duration: Duration refers to how long a single contraction lasts from start to finish, not the time between contractions.

B. Acme: Acme refers to the peak of the contraction, not the time between contractions.

C. Frequency: Frequency refers to the time from the beginning of one contraction to the beginning of the next contraction.

D. Onset: Onset refers to the start of an individual contraction, not the interval between contractions.

Correct Answer is []

Explanation

Potential Complication:

Variable Fetal Heart Rate Decelerations: Variable decelerations are typically associated with cord compression, which may occur during labor, especially with oligohydramnios (low amniotic fluid). The fetal heart rate drops to 100 bpm with contractions but recovers within 30 seconds, fitting the description of variable decelerations. Since amniotic fluid cushions the umbilical cord, a reduction in fluid can increase the likelihood of cord compression.

Actions to Take:

Turn client to left side: Repositioning the client to the left lateral position can relieve pressure on the umbilical cord, improve blood flow to the placenta, and reduce the occurrence of variable decelerations.
Initiate amnioinfusion: An amnioinfusion is a procedure where a sterile fluid is introduced into the uterus to increase the amount of amniotic fluid, reducing cord compression and improving fetal oxygenation. This can help alleviate variable decelerations caused by oligohydramnios.

Parameters to Monitor:

Fetal Heart Rate Baseline: Monitoring the fetal heart rate baseline is essential to assess if the decelerations are improving after interventions, ensuring the fetus is not in distress and maintaining an appropriate heart rate (120–160 bpm).
Uterine Contraction Frequency: Monitoring the frequency of contractions is important, especially if an amnioinfusion is performed, to ensure contractions are not becoming too frequent or too intense, which could further compromise fetal oxygenation and lead to distress.

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A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is measured from the beginning of one contraction to the beginning of the next contraction?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse. Which of the following statements should the nurse include?

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The 5 factors that affect and define the labor and birth process are:

The nurse is preparing to assist the nurse midwife with an amnioinfusion. The patient asks, "Why do I need this?" The best response by the nurse is:

A nurse is reading a Fetal monitor strip and notes accelerations. What interventions would the nurse anticipate to do next?

What is the most common cause of early decelerations in fetal heart rate?

What stage of labor ends with the physiologic stabilization of the mother?

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