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A nurse is assessing a laboring person who is receiving oxytocin for labor induction. What is the most important intervention to prevent uterine hyperstimulation?
- A. monitor fetal heart rate
- B. increase fetal monitoring
- C. administer an epidural
- D. monitor contractions
Correct Answer: B
Rationale: The correct answer is B: increase fetal monitoring. Monitoring the fetus closely is crucial to detect signs of uterine hyperstimulation, such as non-reassuring fetal heart rate patterns. This allows for timely interventions to prevent fetal distress or hypoxia. Monitoring contractions (choice D) is important but does not directly address fetal well-being. Administering an epidural (choice C) may help manage pain but does not prevent uterine hyperstimulation. While monitoring fetal heart rate (choice A) is important, increasing the frequency of monitoring (choice B) is more specific to detecting complications related to oxytocin-induced uterine hyperstimulation.
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The nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with a urinary tract infection (UTI). Which of the following interventions should the nurse prioritize?
- A. Administer antibiotics as prescribed.
- B. Encourage the patient to drink cranberry juice.
- C. Provide education about the signs of preterm labor.
- D. Schedule a follow-up ultrasound to assess fetal health.
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics as prescribed. The priority is to treat the UTI to prevent potential harm to the patient and fetus. Antibiotics are necessary to eliminate the infection and reduce the risk of complications. Encouraging cranberry juice (B) may be beneficial for prevention but is not sufficient to treat an existing UTI. Providing education about preterm labor signs (C) is important but addressing the infection is the immediate concern. Scheduling a follow-up ultrasound (D) may be necessary later but does not address the urgent need to treat the UTI.
A patient in labor is at 6 cm dilation and requests an epidural. What is the most appropriate response from the nurse?
- A. You need to be at least 8 cm dilated for an epidural.
- B. You can have the epidural now since you are in active labor.
- C. The epidural can be administered after the second stage of labor.
- D. An epidural is only administered during the latent phase of labor.
Correct Answer: B
Rationale: The correct answer is B: "You can have the epidural now since you are in active labor." At 6cm dilation, the patient is typically considered to be in active labor, making it an appropriate time to offer an epidural for pain relief. Administering the epidural at this stage can help manage the pain effectively and provide relief during the remainder of labor. Other choices are incorrect because waiting until 8cm dilation (Choice A) may cause unnecessary suffering, administering after the second stage (Choice C) is too late for pain relief, and giving it during the latent phase (Choice D) is not ideal as the patient may not be in active labor yet.
A nurse is caring for a laboring person who is experiencing irregular fetal heart rate patterns. What is the most appropriate intervention?
- A. increase oxygen flow
- B. increase fetal monitoring
- C. administer an analgesic
- D. increase fluid intake
Correct Answer: B
Rationale: The correct answer is B, to increase fetal monitoring. This is crucial to assess the fetal well-being and identify any potential distress or complications early on. Monitoring allows for timely interventions to be implemented to optimize outcomes. Increasing oxygen flow (A) may be necessary in some cases, but it is not the initial priority. Administering an analgesic (C) may help with pain management but does not address the fetal heart rate patterns. Increasing fluid intake (D) is important for hydration but is not directly related to managing fetal heart rate patterns.
The nurse is caring for a pregnant patient who is at 36 weeks gestation and reports severe lower back pain. What should the nurse recommend?
- A. Administer pain medication and ensure the patient rests.
- B. Encourage the patient to engage in light physical activity and maintain good posture.
- C. Instruct the patient to apply heat or cold packs to relieve pain.
- D. Encourage the patient to lie flat on her back for extended periods.
Correct Answer: B
Rationale: The correct answer is B because engaging in light physical activity and maintaining good posture can help alleviate lower back pain during pregnancy by strengthening muscles and improving circulation. Resting may worsen the pain. Applying heat or cold packs may provide temporary relief but does not address the underlying issue. Lying flat on her back for extended periods can lead to decreased blood flow to the uterus and potentially harm the baby.
A nurse is preparing a laboring person for an epidural. What is the most important intervention before the procedure?
- A. ensure informed consent
- B. assist with proper positioning
- C. check for allergies to anesthesia
- D. educate on wound care
Correct Answer: C
Rationale: The correct answer is C: check for allergies to anesthesia. Before administering an epidural, it is crucial to check for any allergies to anesthesia to prevent potential allergic reactions. This step ensures the safety and well-being of the laboring person. Informed consent (choice A) is important but not the most critical step before an epidural. Proper positioning (choice B) is essential during the procedure but not the top priority before it. Educating on wound care (choice D) is not directly relevant to preparing for an epidural.