Nokea
A 40-week pregnant woman is admitted to the labor and delivery unit and is in active labor. Her cervix is 8 cm dilated, and she is experiencing strong contractions. What is the next priority action?
- A. Administer an epidural block
- B. Perform a vaginal examination to assess fetal descent
- C. Assess the fetal heart rate
- D. Prepare for delivery
Correct Answer: C
Rationale: The correct answer is C: Assess the fetal heart rate. This is the next priority action because monitoring the fetal heart rate is crucial to ensure the well-being of the baby during labor. It helps in identifying any signs of fetal distress and guides the healthcare provider in making timely interventions to prevent complications. Administering an epidural block (choice A) can be considered later once the fetal well-being is ensured. Performing a vaginal examination (choice B) may not be necessary at this moment as the woman is already in active labor and has progressed to 8 cm dilation. Preparing for delivery (choice D) should only be done after assessing the fetal well-being to ensure a safe delivery.
You may also like to solve these questions
The nurse is counseling a pregnant patient who is concerned about gestational diabetes. The patient has a family history of diabetes and is overweight. Which statement by the nurse would be most appropriate?
- A. Gestational diabetes usually resolves after delivery and will not affect your baby.
- B. Gestational diabetes can cause excessive birth weight, which may lead to delivery complications.
- C. You should avoid eating carbohydrates entirely to manage gestational diabetes.
- D. Gestational diabetes has no impact on your risk for developing type 2 diabetes later in life.
Correct Answer: B
Rationale: The correct answer is B because gestational diabetes can indeed cause excessive birth weight, leading to delivery complications such as shoulder dystocia and cesarean section. This is important for the patient to be aware of to ensure the health and safety of both herself and her baby.
Choice A is incorrect because gestational diabetes can persist after delivery and may increase the risk of developing type 2 diabetes later in life for both the mother and the baby.
Choice C is incorrect because pregnant women with gestational diabetes still need carbohydrates for proper nutrition; however, they should monitor their carbohydrate intake and choose complex carbohydrates to manage blood sugar levels.
Choice D is incorrect because having gestational diabetes does increase the risk of developing type 2 diabetes later in life. It is important for the patient to understand this potential risk and take steps to manage their health accordingly.
A nurse is caring for a postpartum person who is at risk for uterine atony. What is the most important intervention to prevent uterine atony?
- A. administer uterotonic medications
- B. perform fundal massage
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: B
Rationale: The correct answer is B: perform fundal massage. Fundal massage helps stimulate uterine contractions and prevents uterine atony by promoting uterine firmness and reducing the risk of excessive bleeding. It is a non-invasive intervention that can be done immediately after delivery to prevent postpartum hemorrhage. Administering uterotonic medications (Choice A) may be necessary in severe cases but fundal massage is the initial intervention. Performing a vaginal exam (Choice C) is not indicated unless there are specific concerns or indications. Monitoring vital signs (Choice D) is important but addressing uterine atony requires more direct intervention like fundal massage.
At what point in prenatal development do the lungs begin to produce surfactant?
- A. 17 weeks
- B. 20 weeks
- C. 25 weeks
- D. 30 weeks
Correct Answer: C
Rationale: During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur.
Which of the following findings in an 8-week gestation client, G2 P1001, should the nurse highlight for the nurse midwife? Select all that apply.
- A. Body mass index of 17 kg/m².
- B. Rubella titer of 1:8.
- C. Blood pressure of 100/60 mm Hg.
- D. Hematocrit of 30%.
Correct Answer: A
Rationale: A low BMI, low rubella titer, and low hematocrit are all concerning findings that should be highlighted for further evaluation. A blood pressure of 100/60 mm Hg is within normal limits.
A nurse is caring for a laboring person who is in the third stage of labor. What is the most appropriate nursing intervention during this stage?
- A. assist with the delivery of the placenta
- B. prepare for a vaginal birth
- C. administer oxytocin
- D. apply gentle pressure to the uterus
Correct Answer: A
Rationale: The correct answer is A: assist with the delivery of the placenta. During the third stage of labor, the placenta needs to be delivered. This is done by gently applying traction to the umbilical cord while supporting the uterus to facilitate the expulsion of the placenta. This step is crucial to prevent postpartum hemorrhage.
Choice B (prepare for a vaginal birth) is incorrect because the person is already in the third stage of labor, which means the baby has been delivered and they are now focusing on delivering the placenta.
Choice C (administer oxytocin) is incorrect because while oxytocin may be used to help control bleeding after the placenta is delivered, it is not the most appropriate intervention during the third stage of labor.
Choice D (apply gentle pressure to the uterus) is incorrect because direct pressure to the uterus is not the primary intervention during the third stage of labor; assisting with the delivery of the placenta takes precedence.