Labor Landmarks
A nurse notes cervical dilation has progressed from 6 cm to 8 cm in one hour with strong contractions every 2 minutes. This indicates:
What is the active phase of labor?
Bright red, painless bleeding in the third trimester requires the nurse to avoid this action.
What is performing a vaginal exam?
This sign refers to the softening of the cervix that occurs in early pregnancy.
What is Goodell’s sign?
A patient receiving Oxytocin develops late decelerations. The nurse’s priority action is:
What is stop the oxytocin infusion?
When startled by a loud noise, a newborn flings arms out and then pulls them back in. This reflex helps identify neurological integrity.
What is the Moro reflex?
A patient is 4 cm dilated, 80% effaced, with contractions every 5 minutes. This phase of labor is most consistent with:
What is the latent phase of the first stage of labor?
A pregnant patient presents with hypertension, edema, and proteinuria. The nurse knows the definitive treatment for Preeclampsia is:
What is delivery of the fetus?
This sign is the softening of the lower part of the uterus, felt during a pelvic exam.
What is Hegar’s sign?
Magnesium sulfate is administered to patients with Preeclampsia primarily to achieve this therapeutic effect.
What is seizure prevention?
A newborn makes stepping movements when held upright with feet on a surface. This reflex indicates normal neuromuscular development.
What is the stepping reflex?
A nurse notes cervical dilation has progressed from 6 cm to 8 cm in one hour with strong contractions every 2 minutes. This indicates:
What is the active phase of labor?
A patient with severe preeclampsia reports a severe headache and visual changes. This indicates increased risk for:
What is eclampsia (seizures)?
During an early prenatal exam, a nurse notices the uterus bends easily at the junction of the cervix and body. This finding is a classic probable sign of pregnancy.
What is McDonald’s sign?
In addition to stopping magnesium sulfate, the nurse should prepare to administer this reversal agent:
What is calcium gluconate?
Failure of the rooting reflex may interfere with this essential newborn function.
What is breastfeeding?
A prolonged second stage increases the risk for this maternal complication related to uterine muscle fatigue.
What is postpartum hemorrhage?
A patient with Gestational Diabetes is at highest risk for this newborn complication immediately after birth.
What is hypoglycemia?
A pregnant patient at 12 weeks notices brownish patches on her cheeks and forehead. The nurse explains this common, harmless condition is caused by hormonal changes stimulating melanin production.
What is chloasma (or mask of pregnancy)?
If a patient on oxytocin has >5 contractions in 10 minutes, the nurse’s first action is to do this.
What is stop the infusion?
An asymmetric Moro reflex may indicate this type of birth injury.
What is a clavicle fracture (or brachial plexus injury)?
During transition phase, the patient becomes agitated and reports severe rectal pressure. The nurse’s best action is
What is assess for fetal descent and urge to push?
A 34-week pregnant patient presents with sudden, severe abdominal pain, dark vaginal bleeding, and a rigid, tender uterus. Fetal heart rate shows bradycardia. This obstetric emergency requires immediate intervention to prevent fetal and maternal complications.
What is placental abruption?
Chadwick’s sign occurs due to this physiological change in early pregnancy.
What is increased blood flow (vascularity)?
A patient receiving oxytocin has 6 contractions in 10 minutes. After stopping the infusion, the nurse should next:
What is reposition the patient (side-lying) and administer oxygen?
A weak or absent sucking reflex in a newborn places the infant at risk for this complication.
What is poor feeding (or failure to thrive)?