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A nurse is assisting a laboring person with an epidural. What is the most important nursing intervention prior to the procedure?
- A. ensure proper positioning
- B. ensure informed consent
- C. monitor contractions
- D. assist with controlled breathing
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent. This is crucial before any medical procedure, including epidural administration. It ensures the laboring person understands the risks, benefits, and alternatives of the epidural. Proper positioning (choice A) is important during the procedure but not the most critical pre-procedure intervention. Monitoring contractions (choice C) and assisting with breathing (choice D) are important aspects of labor support but not directly related to obtaining informed consent for the epidural.
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A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.
A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
- A. ensure the birthing person is in a sitting position
- B. check for allergies to anesthesia
- C. ensure informed consent is obtained
- D. administer IV fluids
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically.
Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
- A. perform fundal massage
- B. administer a uterotonic medication
- C. perform a vaginal exam
- D. monitor vital signs
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.
Which is an expected characteristic of amniotic fluid?
- A. Deep yellow color
- B. Clear, with small white particles
- C. Nitrazine test: acidic result
- D. Absence of ferning
Correct Answer: B
Rationale: The correct answer is B: Clear, with small white particles. Amniotic fluid is typically clear with small white particles, representing vernix caseosa. Vernix caseosa is a white, cheese-like substance that covers the skin of the fetus. It helps protect the skin and regulate body temperature. The presence of vernix particles in amniotic fluid is a normal and expected characteristic.
Incorrect choices:
A: Deep yellow color - Amniotic fluid is usually clear or slightly straw-colored. A deep yellow color may indicate the presence of meconium, which suggests fetal distress.
C: Nitrazine test: acidic result - Amniotic fluid is normally alkaline, not acidic. An acidic result may indicate infection.
D: Absence of ferning - Ferning is a characteristic pattern seen under a microscope in dried cervical mucus, not amniotic fluid. Absence of ferning in amniotic fluid is not a relevant characteristic.
The nurse discusses sexual intimacy with a pregnant couple. Which of the following should be included in the teaching plan?
- A. Vaginal intercourse should cease by the beginning of the third trimester.
- B. Breast fondling should be discouraged because of the potential for preterm labor.
- C. The couple may find it necessary to experiment with alternate positions.
- D. Vaginal lubricant should be used sparingly throughout the pregnancy.
Correct Answer: C
Rationale: Experimenting with alternate positions is often necessary due to changing body dynamics during pregnancy. Vaginal intercourse does not need to stop unless medically advised, breast fondling is unlikely to induce labor, and vaginal lubricants can be used as needed.