Nokea
A 32-week pregnant woman is admitted to the labor and delivery unit with contractions every 5 minutes. What is the most appropriate intervention?
- A. Administer magnesium sulfate to stop the contractions
- B. Start an IV and monitor the fetal heart rate
- C. Perform a cesarean section immediately
- D. Encourage the patient to push to deliver the baby
Correct Answer: B
Rationale: The correct answer is B: Start an IV and monitor the fetal heart rate. This is the most appropriate intervention as it allows for assessment of fetal well-being and maternal status. IV access is crucial for potential interventions like administering medications or fluids. Monitoring fetal heart rate helps determine fetal distress. Administering magnesium sulfate (choice A) should be considered for preterm labor, not routine contractions. Performing a cesarean section immediately (choice C) is not indicated without proper evaluation. Encouraging the patient to push (choice D) is premature without assessing cervical dilation.
You may also like to solve these questions
The nurse is educating a pregnant patient about the importance of taking prenatal vitamins. Which of the following statements by the patient indicates effective teaching?
- A. I should take prenatal vitamins only during the first trimester.
- B. I should take prenatal vitamins throughout the pregnancy to ensure my baby gets the nutrients it needs.
- C. I should stop taking prenatal vitamins after the baby is born.
- D. I can get all the necessary nutrients from my diet without taking prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because taking prenatal vitamins throughout pregnancy ensures the baby receives essential nutrients for growth and development. Prenatal vitamins contain key nutrients like folic acid, iron, and calcium crucial for the baby's health. Choice A is incorrect because prenatal vitamins are recommended throughout pregnancy, not just the first trimester. Choice C is incorrect as prenatal vitamins may be needed postpartum if breastfeeding. Choice D is incorrect as prenatal vitamins provide additional nutrients that may not be obtained solely from diet.
A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during the pushing phase?
- A. assist the person into a squatting position
- B. instruct the person to push with contractions
- C. coach the person through controlled pushing
- D. prepare for spontaneous delivery
Correct Answer: D
Rationale: The correct answer is D: prepare for spontaneous delivery. During the pushing phase of the second stage of labor, the most appropriate nursing intervention is to prepare for the spontaneous delivery of the baby. This involves ensuring that all necessary equipment and supplies are ready for the delivery, positioning oneself appropriately to assist with the birth, and being prepared to provide immediate care to the newborn. This intervention is crucial to ensure a safe and smooth delivery process.
Choice A (assist the person into a squatting position) may not be appropriate for all laboring individuals and may not facilitate the most effective pushing efforts. Choice B (instruct the person to push with contractions) is a general instruction that may not encompass all the necessary aspects of supporting the delivery process. Choice C (coach the person through controlled pushing) may be too restrictive and not allow for the natural progression of labor. Thus, the most appropriate intervention is to prepare for spontaneous delivery to ensure readiness and safety for both the laboring person and the newborn.
A nurse is monitoring a laboring person's vital signs during the first stage of labor. Which vital sign change is most likely to indicate the need for further evaluation?
- A. decrease in heart rate
- B. increase in blood pressure
- C. increase in pulse rate
- D. no change in vital signs
Correct Answer: B
Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby.
A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions.
C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high.
D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.
What is the most appropriate action when a laboring person's membranes rupture and meconium is present?
- A. notify the healthcare provider
- B. document the amount of meconium
- C. prepare the person for vacuum extraction
- D. apply pressure to the abdomen
Correct Answer: A
Rationale: The correct answer is A: notify the healthcare provider. This is the most appropriate action because the presence of meconium in the amniotic fluid indicates potential fetal distress, requiring immediate medical evaluation. Notifying the healthcare provider allows for prompt assessment and necessary interventions to ensure the well-being of both the laboring person and the baby. Documenting the amount of meconium (choice B) may be important for the medical record but is not the priority in this situation. Choices C and D, preparing for vacuum extraction and applying pressure to the abdomen, are not indicated and could potentially harm the baby or the laboring person.
Can the baby's sex be determined at 8 weeks' gestation?
- A. Doctor knows the sex
- B. Organs are formed but too small
- C. Technician sees a penis
- D. It will take another month
Correct Answer: D
Rationale: At 8 weeks, organs are developing but too small to determine sex; this usually occurs around 18–20 weeks.