Nokea
A 36-week pregnant woman presents to the labor and delivery unit in preterm labor. What is the priority intervention?
- A. Administer corticosteroids to promote fetal lung maturity
- B. Administer magnesium sulfate to stop labor
- C. Perform an emergency cesarean section
- D. Perform a nonstress test (NST)
Correct Answer: A
Rationale: The correct answer is A: Administer corticosteroids to promote fetal lung maturity. This is the priority intervention in preterm labor as it helps accelerate fetal lung development, reducing the risk of respiratory distress syndrome. Administering magnesium sulfate (B) is used for neuroprotection in preterm labor but is not the priority in this case. Emergency cesarean section (C) is not indicated unless there is a life-threatening situation. Performing a nonstress test (D) is important for fetal monitoring but is not the priority intervention in this scenario.
You may also like to solve these questions
A nurse is caring for a birthing person who is experiencing a late deceleration in fetal heart rate. What is the most appropriate action for the nurse to take?
- A. turn the laboring person to the left side
- B. increase maternal oxygen supply
- C. prepare for an emergency cesarean section
- D. administer terbutaline
Correct Answer: A
Rationale: The correct action for a nurse when a birthing person experiences late deceleration in fetal heart rate is to turn the laboring person to the left side. This helps improve placental perfusion by reducing pressure on the vena cava, enhancing blood flow to the uterus, and thus improving oxygenation to the fetus. This action can help alleviate the late deceleration and prevent fetal distress. Increasing maternal oxygen supply (choice B) is important but not the first-line intervention for late decelerations. Emergency cesarean section (choice C) is not typically indicated for late decelerations unless other interventions fail. Administering terbutaline (choice D) is not appropriate for late decelerations as it is a tocolytic used to inhibit uterine contractions and prevent preterm labor.
The nurse has taken a health history on four primigravid clients at their first prenatal visits. It is high priority that which of the clients receives nutrition counseling?
- A. The woman diagnosed with phenylketonuria.
- B. The woman who has Graves’ disease.
- C. The woman with Cushing’s syndrome.
- D. The woman diagnosed with myasthenia gravis.
Correct Answer: A
Rationale: Phenylketonuria (PKU) requires strict dietary management, especially during pregnancy, to prevent harm to the fetus. The other conditions do not have the same immediate dietary implications.
A pregnant patient at 30 weeks gestation reports swelling in her legs and feet. Which of the following interventions should the nurse recommend?
- A. Increase fluid intake to reduce swelling.
- B. Lie down flat on your back to relieve swelling.
- C. Elevate the legs while sitting or lying down.
- D. Limit physical activity and avoid walking.
Correct Answer: C
Rationale: The correct answer is C: Elevate the legs while sitting or lying down. This intervention helps reduce swelling by promoting venous return and reducing fluid accumulation in the lower extremities. Elevating the legs helps gravity assist in returning blood back to the heart, reducing edema. Increasing fluid intake (A) may worsen swelling. Lying flat on the back (B) can restrict blood flow and worsen swelling. Limiting physical activity (D) can lead to decreased circulation and exacerbate swelling.
What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse?
- A. Age
- B. Estrogen level
- C. Body temperature
- D. Level of feminine hygiene
Correct Answer: B
Rationale: Estrogen levels and the pH of the female reproductive tract can affect the survival of the X- and Y-bearing sperm as well as their motility.
During a vaginal birth, a birthing person experienced a second-degree perineal laceration. What is a characteristic of a second-degree laceration?
- A. It involves only the vaginal mucosa.
- B. It extends through the vaginal and perineal muscles.
- C. It is the least severe type of laceration.
- D. It does not require suturing.
Correct Answer: B
Rationale: The correct answer is B because a second-degree perineal laceration extends through the vaginal mucosa and perineal muscles. First, a second-degree laceration involves more than just the vaginal mucosa, as it also affects the perineal muscles. This type of laceration is more severe than a first-degree laceration, which only involves the vaginal mucosa. Second, due to the involvement of deeper structures like the perineal muscles, suturing is typically required to promote proper healing and prevent complications. Therefore, choice B is correct. Choices A and C are incorrect because a second-degree laceration involves more than just the vaginal mucosa and is not the least severe type of laceration. Choice D is incorrect because suturing is usually necessary for second-degree lacerations.