Maternity Nursing Test II (Practice Mode)

The placenta must be inspected for completeness to include the membranes because an incomplete placenta could mean that there is retention of placental fragments which can lead to uterine atony. If the uterus does not contract adequately, hemorrhage can occur.

The nurse should check right away for possible cord coil around the neck because if it is present, the baby can be strangulated by it and the fetal head will have difficulty being delivered.

The common oxytocin given to enhance uterine contraction is pitocin. This is also the drug given to induce labor.

Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that maybe present allowing for better breathing. Also, if mucus is in the nose and mouth, aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby’s head has come out as given in the situation.)

Full bladder can impede the descent of the fetal head. The nurse can readily manage this problem by doing a simple catheterization of the mother.

During the pregnancy, there is an increase in maternal blood volume to accommodate the need of the fetus. When the baby and placenta have been delivered, there is a fluid shift back to the maternal circulation as part of physiologic adaptation during the postpartum period. In cesarean section, the fluid shift occurs faster because the placenta is taken out right after the baby is delivered giving it less time for the fluid shift to gradually occur.

Partograph is a monitoring tool designed by the World Health Organization for use by health workers when attending to mothers in labor especially the high risk ones. For maternal parameters all of the above is placed in the partograph except the fluid intake since this is placed in a separate monitoring sheet.

The normal color of amniotic fluid is clear like water. If it is yellowish, there is probably Rh incompatibility. If the color is greenish, it is probably meconium stained.

The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. Observe strict asepsis in the care of the cord to prevent infection. The cord has to be kept moist to prevent it from drying. Don’t attempt to put back the cord into the vagina but relieve pressure on the cord by positioning the mother either on trendellenberg or sims position

The umbilical cord is composed of 2 arteries and 1 vein.

The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. Flexion, internal rotation and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus.

Station is defined as the relationship of the fetal head and the level of the ischial spine. At the level of the ischial spine, the station is “0”. Above the ischial spine it is considered (-) station and below the ischial spine it is (+) station.

he nurse should check if there is a cord coil because the baby will not be delivered safely if the cord is coiled around its neck. Wiping of the face should be done seconds after you have ensured that there is no cord coil but suctioning of the nose should be done after the mouth because the baby is a “nasal obligate” breather. If the nose is suctioned first before the mouth, the mucus plugging the mouth can be aspirated by the baby.

Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of baby. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix.

For normal vaginal delivery, the nurse needs only the instruments for cutting the umbilical cord such as: 2 clamps (straight or curve) and a pair of scissors as well as the kidney basin to receive the placenta. The retractor is not part of the basic set. In the hospital setting, needle holder and tissue forceps are added especially if the woman delivering the baby is a primigravida wherein episiotomy is generally done.

The term floating means the fetal presenting part has not entered/descended into the pelvic inlet. If the fetal head has entered the pelvic inlet, it is said to be engaged.

All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and boundaries not well defined, the cause of the hemorrhage could be uterine atony.

In false labor, the contractions remain to be irregular in intensity and duration while in true labor, the contractions become stronger, longer and more frequent.

The placenta is delivered within 30 minutes from the delivery of the baby. If it takes longer, probably the placenta is abnormally adherent and there is a need to refer already to the obstetrician.

Acme is the technical term for the highest point of intensity of a uterine contraction.

There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion comes out first, it is called the Schultze mechanism; while if the meaty portion comes out first, it is called the Duncan mechanism.

Forceps delivery under epidural anesthesia will make the delivery process less painful and require less effort to push for the mother. Pushing requires more effort which a compromised heart may not be able to endure.

Duration of a uterine contraction refers to one contraction. Thus it is correctly measure from the beginning of one contraction to the end of the same contraction and not of another contraction.

Induced Abortion is illegal in the country as stated in our Penal Code and any person who performs the act for a fee commits a grave offense punishable by 10-12 years of imprisonment.

Uterine contraction is the primary force that will expel the fetus out through the birth canal Maternal bearing down is considered the secondary power/force that will help push the fetus out.

The normal fetal heart rate will decelerate (go down) slightly during a contraction because of the compression on the fetal head. However, the heart rate should go back to the pre-contraction rate as soon as the contraction is over since the compression on the head has also ended.

In stage 1 during a normal vaginal delivery of a vertex presentation, the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor.

Ritgen’s technique is done to prevent perineal tear. This is done by the nurse by support the perineum with a sterile towel and pushing the perineum downard with one hand while the other hand is supporting the baby’s head as it goes out of the vaginal opening.

The action of oxytocin is to make the uterus contract as well make the cervix close. If it is given prior to placental delivery, the placenta will be trapped inside because the action of the drug is almost immediate if given parentally.

When the placenta is still attached to the uterine wall, tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached.

Viability means the capability of the fetus to live/survive outside of the uterine environment. With the present technological and medical advances, 21 weeks AOG is considered as the minimum fetal age for viability.

In general, when the heart is compromised such as in maternal cardiac condition, the condition can lead to less blood supply to the uterus consequently to the placenta which provides the fetus with the essential nutrients and oxygen. Thus if the blood supply is less, the baby will suffer from chronic hypoxia leading to a small-for-gestational age condition.

Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. The perineal area is the one being prepared for the delivery and must be kept clean

Placental detachment does not require the mother to bear down. A normal placenta will detach by itself without any effort from the mother.

The primary power of labor and delivery is the uterine contraction. This should be augmented by the mother’s bearing down during a contraction.

Frequency of the uterine contraction is defined as from the beginning of one contraction to the beginning of another contraction.

For nullipara the normal cervical dilatation should be 1.2 cm/hr. If it is less than that, it is considered a protracted active phase of the first stage. For multipara, the normal cervical dilatation is 1.5 cm/hr.

After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head.

Breech presentation means the buttocks of the fetus is the presenting part. If it is only the foot/feet, it is considered footling. If only the buttocks, it is frank breech. If both the feet and the buttocks are presenting it is called complete breech.

The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the FHR usually goes down but must return to its pre-contraction rate after the contraction ends.

all the above conditions can occur following a precipitate labor and delivery of the fetus because there was little time for the baby to adapt to the passageway. If the presentation is cephalic, the fetal head serves as the main part of the fetus that pushes through the birth canal which can lead to cranial hematoma, and possible compression of cord may occur which can lead to less blood and oxygen to the fetus (hypoxia). Likewise the maternal passageway (cervix, vaginal canal and perineum) did not have enough time to stretch which can lead to laceration.

Narcotic analgesics must be given when uterine contractions are already well established so that it will not cause stoppage of the contraction thus protracting labor. Also, it should be given when delivery of fetus is imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can pass through placental barrier.

The landmark used in determine fetal position is the posterior fontanel because this is the nearest to the occiput. So if the nurse palpated the occiput (O) at the left (L) side of the mother and at the upper/anterior (A) quadrant then the fetal position is LOA.

In monitoring the intensity of the contraction the best place is to place the fingertips at the fundal area. The fundus is the contractile part of the uterus and the fingertips are more sensitive than the palm of the hand.

The pelvis is a bony structure that is part of the passageway but is not flexible. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus.

The Philippine Constitution of 1987 guarantees the right of the unborn child from conception equal to the mother as stated in Article II State Policies, Section 12.

The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete. Also, the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels, 2 veins and 1 artery.

Ritgen’s method is used to prevent perineal tear/laceration during the delivery of the fetal head. Lamaze method is also known as psychoprophylactic method and Dick-Read method are commonly known natural childbirth procedures which advocate the use of non-pharmacologic measures to relieve labor pain.

The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour. Since the time lapsed is already 2 hours, the dilatation is expected to be already 8 cm. Hence, the active phase is protracted.

Shaving is done to prevent infection and the area usually shaved should sufficiently cover the area for surgery, cesarean section. The pubic hair is definitely to be included in the shaving