NR-327 Maternal-Child Nursing - Set 3 - Part 3

Correct Answer: Applying firm counterpressure against the sacrum

Sacral counterpressure with the heel of the hand opposes the occiput pressing on the sacrum and is the single best measure for occiput posterior back labor. Hands and knees positioning adds further relief. Option a is incorrect because light abdominal stroking suits the diffuse cramping of early first stage labor. It cannot reach the mechanical pressure of an occiput grinding against the maternal sacrum. Option b is incorrect because cold does help back pain, yet placing it on the abdomen aims the treatment at the wrong site. The sacrum, not the abdominal wall, is generating this pain. Option d is incorrect because a supine position presses the fetal occiput harder into the sacrum and compresses the vena cava. Both effects worsen her pain and reduce blood flow to the placenta.

Correct Answer: Normal uterine activity with adequate resting tone

Five or fewer contractions in ten minutes, a resting interval of at least a minute and a uterus that relaxes fully describe expected labor. Nothing here calls for intervention. Option a is incorrect because tachysystole means more than five contractions in ten minutes averaged across half an hour. A pattern spaced three minutes apart falls well inside the accepted limit. Option b is incorrect because elevated resting tone means the uterus never fully relaxes, and this one softens between contractions. The interval described also exceeds the sixty seconds the fetus needs. Option c is incorrect because labor adequacy is judged by cervical change and by contraction strength, which palpation grades as mild, moderate or strong. This description gives no reason to add medication.

Correct Answer: "Real contractions start in my back and keep going when I walk."

True labor discomfort begins in the lower back and radiates around to the abdomen, and it persists or strengthens with ambulation. That pattern, along with cervical change, separates it from Braxton Hicks tightening. Option a is incorrect because relief with walking points toward false labor, not real labor. The client has the effect reversed, so she needs reteaching before discharge about how ambulation changes each pattern. Option c is incorrect because lengthening and shortening intervals belong to true labor, where contractions build steadily. Braxton Hicks tightening stays short, spaces out unpredictably, and often fades entirely with rest or hydration. Option d is incorrect because a warm bath is one of the comfort measures that quiets false labor while leaving true labor untouched. That very difference is what the nurse wants her to use.

Correct Answer: The first is benign; the second signals placental insufficiency

A nadir that lines up with the contraction peak is an early deceleration from head compression and needs nothing. A nadir that trails the peak is a late deceleration and demands intervention. Option a is incorrect because only the deceleration timed with the peak comes from skull pressure. Delayed recovery after the contraction ends points to a placenta that cannot meet the fetal oxygen demand. Option b is incorrect because depth never determines significance in this pattern. A late deceleration only ten beats deep, paired with absent variability, is more dangerous than a deep early one. Option c is incorrect because the labels are reversed. Cord compression makes an abrupt jagged dip that can land anywhere, while both decelerations described here fall and rise gradually with the contraction.

Correct Answer: The second stage of labor has begun

Complete dilation opens the second stage, and the fetal head pressing on the pelvic floor triggers the Ferguson reflex, producing an irresistible urge to bear down and a bulging perineum. Option a is incorrect because the third stage starts only after the infant is born and lasts until the placenta delivers. This client still has a fetus inside the uterus. Option b is incorrect because active labor was already underway an hour earlier at seven centimeters. Rectal pressure and a bulging perineum signal progress well past that middle stretch of dilation. Option d is incorrect because the latent phase covers the first few centimeters and ended long before this point. A client feeling rectal pressure is nowhere near the opening stretch of labor.

Correct Answer: The membranes must be ruptured

An internal electrode is screwed into the presenting part, so the membranes must be ruptured, the cervix dilated at least two centimeters, and the presenting part reachable and identifiable. Option b is incorrect because regional anesthesia has no bearing on placing an electrode; the prerequisites are anatomic access to the fetal head, not the client's comfort measures during labor. Option c is incorrect because gestational age is not a listed requirement, although extreme prematurity is one reason to avoid the spiral wire. Ruptured membranes and cervical dilation are the true gatekeepers. Option d is incorrect because complete dilation is far more than the electrode needs; roughly two centimeters is enough, and waiting until ten would waste most of the labor it is meant to monitor.

Correct Answer: Massage the fundus until it firms

Massage is immediate, independent and often enough by itself. A soft uterus cannot clamp the vessels where the placenta was attached, and firm tone stops the bleeding faster than any other step. Option a is incorrect because emptying the bladder comes second, right after massage, when a displaced fundus suggests urine is in the way. Catheterization also takes time this bleeding client does not have. Option c is incorrect because a drug requires an order and several minutes to work. Uterotonics follow massage and bladder emptying when tone still will not hold, so they are never the opening move. Option d is incorrect because laceration is suspected when bleeding continues while the fundus stays firm. Here the uterus is soft, which names atony as the source and puts a nursing action first.

Correct Answer: Coach her to blow out through each contraction

Blowing or panting prevents the closed glottis effort that jams the head against an incompletely opened cervix. Pushing on that rim swells it and can tear the cervix during birth. Option b is incorrect because voluntary effort never opens a cervix; contractions do that work alone. Driving the head into a remaining lip produces edema and lacerations rather than the last two centimeters. Option c is incorrect because a supine position with the legs pulled back sets up for pushing, which is exactly what must wait. It also invites the hypotension that flat positioning causes. Option d is incorrect because comfort measures alone leave the client bearing down on a cervical lip. Ice chips address a dry mouth, not the mechanical harm happening with every forceful effort.

Correct Answer: The second, palpating the sides of the uterus

The second maneuver palpates each side of the uterus to find the smooth firm fetal back. Heart tones are transmitted through that back, so it marks the spot where the transducer belongs. Option a is incorrect because the fundal grip identifies what occupies the top of the uterus, distinguishing a soft irregular breech from a hard ballottable head. It establishes lie and presentation, not transducer placement. Option b is incorrect because grasping above the symphysis assesses the presenting part and whether it has become fixed in the pelvis. Engagement information does not tell the nurse where heart tones will be loudest. Option c is incorrect because the pelvic grip, done facing the client's feet, judges attitude and how far the head has descended. Neither of those findings points to a side of the abdomen.

Correct Answer: Umbilical cord prolapse with cord compression

A sudden prolonged bradycardia immediately following rupture points to cord prolapse, because escaping fluid can sweep the cord ahead of an unengaged head where each contraction squeezes it shut. Option a is incorrect because embolism presents as abrupt maternal respiratory distress, hypotension and collapse followed by bleeding from clotting failure. Nothing in this picture describes the mother deteriorating; only the fetal rate changed. Option b is incorrect because abruption typically brings dark vaginal bleeding, a rigid painful uterus and rising resting tone. The stem reports none of that, and the rate fell the instant fluid escaped. Option d is incorrect because rupture of the uterus follows a scar under strong contractions and announces itself with tearing pain, a palpable change in the fetal position and maternal shock. This client has no such history.