Nokea
A nurse is assessing a laboring person and notes the presence of meconium-stained amniotic fluid. What is the priority nursing action?
- A. prepare for an emergency cesarean section
- B. document the amount of meconium
- C. notify the healthcare provider
- D. prepare the person for a blood transfusion
Correct Answer: D
Rationale: The correct answer is D: prepare the person for a blood transfusion. Meconium-stained amniotic fluid indicates fetal distress, which can lead to hypoxia and potential blood loss in the laboring person. The priority action is to prepare for a potential blood transfusion to address any hemorrhage that may occur during delivery. This is crucial for ensuring the safety and well-being of both the laboring person and the baby.
Incorrect options:
A: Prepare for an emergency cesarean section - While meconium-stained amniotic fluid may indicate fetal distress, the priority is addressing potential maternal blood loss.
B: Document the amount of meconium - Documenting is important but not the priority when the person's health is at risk.
C: Notify the healthcare provider - While important, immediate action to address potential blood loss takes precedence over notifying the healthcare provider.
You may also like to solve these questions
A pregnant patient who is 18 weeks gestation reports that she has not felt her baby move for several hours. What should the nurse instruct the patient to do?
- A. Drink a cold beverage and lie down to count fetal movements.
- B. Wait until the morning and report any continued lack of movement to your doctor.
- C. Rest and refrain from worrying, as it is common for fetal movements to decrease.
- D. Call your doctor immediately to report the decrease in fetal movement.
Correct Answer: A
Rationale: The correct answer is A because decreased fetal movement could indicate a potential problem. Drinking a cold beverage and lying down can stimulate the baby to move, allowing the patient to count fetal movements. This can help assess the baby's well-being. Choice B is incorrect as waiting can delay necessary intervention. Choice C is incorrect as decreased fetal movement should not be dismissed without assessment. Choice D is incorrect as immediate action is needed but calling the doctor alone may not provide immediate relief or guidance.
A woman in labor requests an epidural. What should the nurse assess before administering the epidural?
- A. Cervical dilation
- B. Maternal blood pressure
- C. Fetal heart rate
- D. Maternal temperature
Correct Answer: B
Rationale: The correct answer is B: Maternal blood pressure. Before administering an epidural, it is crucial to assess the maternal blood pressure to ensure it is within the normal range. Hypotension can occur as a common side effect of epidural anesthesia, which can lead to decreased placental perfusion and compromise fetal oxygenation. Assessing maternal blood pressure helps in preventing potential complications.
Incorrect choices:
A: Cervical dilation - Not directly related to the administration of an epidural.
C: Fetal heart rate - Important but not the immediate assessment needed before administering an epidural.
D: Maternal temperature - While it is important in general assessment, it is not specifically required before giving an epidural.
A nurse is caring for a laboring person who is experiencing fetal bradycardia. What is the priority nursing intervention?
- A. administer oxygen
- B. administer IV fluids
- C. increase maternal hydration
- D. increase maternal oxygen
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal bradycardia indicates decreased oxygen supply to the fetus, which can lead to fetal distress. Administering oxygen helps improve oxygen levels in the mother's blood, increasing oxygen delivery to the fetus. This intervention is crucial in preventing further complications and ensuring the well-being of the baby. Administering IV fluids (B) and increasing maternal hydration (C) may be beneficial but do not directly address the immediate need for oxygen. Increasing maternal oxygen (D) is redundant since the primary focus should be on fetal oxygenation.
A nurse is caring for a pregnant patient who is 26 weeks gestation and reports feeling dizzy when standing. What should the nurse recommend to the patient?
- A. Stand up slowly and make sure to drink plenty of fluids.
- B. Sit down immediately and rest for 10 minutes.
- C. Lie flat on your back to increase blood flow to the brain.
- D. Take deep breaths and elevate your legs while sitting.
Correct Answer: A
Rationale: The correct answer is A: Stand up slowly and make sure to drink plenty of fluids. When a pregnant patient feels dizzy when standing, it is likely due to postural hypotension. Standing up slowly helps prevent a sudden drop in blood pressure, which can cause dizziness. Drinking plenty of fluids helps maintain adequate blood volume and prevents dehydration, another common cause of dizziness during pregnancy. Sitting down immediately (B) may help temporarily but does not address the underlying issue. Lying flat on the back (C) can worsen symptoms by putting pressure on the vena cava, reducing blood flow to the brain. Taking deep breaths and elevating legs (D) may not be effective in addressing postural hypotension.
What is the most common cause of shoulder dystocia during delivery?
- A. fetal macrosomia
- B. maternal obesity
- C. maternal diabetes
- D. advanced maternal age
Correct Answer: A
Rationale: The correct answer is A: fetal macrosomia. Fetal macrosomia, defined as a birth weight above 4 kg, is the most common cause of shoulder dystocia during delivery. This occurs when the baby's shoulders get stuck behind the mother's pelvic bone, leading to complications. Macrosomia is more likely in pregnancies with gestational diabetes, maternal obesity, and advanced maternal age, but the primary risk factor for shoulder dystocia is fetal macrosomia due to the large size of the baby. Maternal obesity, diabetes, and advanced age are secondary risk factors that can contribute to the likelihood of shoulder dystocia but are not the primary cause.