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A nurse is caring for a laboring person who is experiencing late decelerations in fetal heart rate. What is the priority nursing intervention?
- A. place the person on their left side
- B. apply oxygen via mask
- C. administer pain medication
- D. perform a vaginal examination
Correct Answer: A
Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.
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A nurse is monitoring a postpartum person for signs of infection. Which finding would be most concerning in the first 24 hours after delivery?
- A. fever
- B. foul-smelling lochia
- C. increased blood pressure
- D. increased heart rate
Correct Answer: A
Rationale: The correct answer is A: fever. A fever in the first 24 hours after delivery is most concerning as it may indicate an infection, such as endometritis, which can lead to serious complications if not promptly treated. Postpartum fever is often the earliest sign of infection due to retained products of conception or ascending genital tract infection. Monitoring for fever is crucial as it can help prevent sepsis. Foul-smelling lochia (choice B) may suggest infection but is not as immediate a concern as fever. Increased blood pressure (choice C) and heart rate (choice D) may be normal physiological responses to delivery and are not specific indicators of infection in the immediate postpartum period.
A nurse is preparing a laboring person for an epidural. What is the priority nursing intervention before the procedure?
- A. ensure informed consent
- B. check for allergies to anesthesia
- C. assess for fetal movement
- D. administer pain relief
Correct Answer: C
Rationale: The correct answer is C: assess for fetal movement. This is the priority intervention before an epidural to ensure the safety and well-being of the fetus. Assessing for fetal movement helps determine the fetal well-being and any potential distress that may require immediate intervention. Ensuring informed consent (A) is important but assessing fetal well-being takes precedence. Checking for allergies to anesthesia (B) is important but not the priority before assessing fetal movement. Administering pain relief (D) can be done after assessing fetal movement to ensure the safety of both the laboring person and the fetus.
During the third stage of labor, the nurse notes excessive bleeding. What should the nurse assess first?
- A. uterine tone
- B. placental separation
- C. vaginal bleeding
- D. cervical dilation
Correct Answer: A
Rationale: During the third stage of labor, the correct answer is A: uterine tone. This is because assessing uterine tone is crucial in determining if the uterus is contracting effectively to control bleeding. If the uterus is not firm (boggy), it can lead to postpartum hemorrhage. Placental separation (B) occurs during the third stage, but assessing uterine tone takes precedence. Vaginal bleeding (C) is a symptom of potential postpartum hemorrhage, which can be caused by poor uterine tone. Cervical dilation (D) is not a priority in this situation as the focus should be on controlling bleeding.
A nurse is caring for a laboring person who is receiving oxytocin for induction of labor. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate continuously
- B. increase maternal hydration
- C. administer IV fluids
- D. assess uterine tone
Correct Answer: C
Rationale: The correct answer is C because administering IV fluids is crucial during oxytocin infusion to prevent maternal dehydration and maintain fluid balance. This helps prevent complications such as uterine hyperstimulation and fetal distress. Monitoring fetal heart rate continuously (choice A) is important but not the priority. Increasing maternal hydration (choice B) is beneficial but does not address the immediate need for fluid replacement. Assessing uterine tone (choice D) is important but secondary to ensuring adequate hydration.
A pregnant patient at 34 weeks gestation is concerned about swelling in her hands, feet, and face. What is the nurse's priority action?
- A. Monitor the patient's blood pressure and check for signs of preeclampsia.
- B. Encourage the patient to rest with her legs elevated.
- C. Administer diuretics to reduce swelling.
- D. Instruct the patient to reduce sodium intake and drink more fluids.
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. At 34 weeks gestation, swelling in the hands, feet, and face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and proteinuria. Monitoring blood pressure is crucial to identify any preeclampsia development. Preeclampsia can lead to complications for both the mother and the baby if left untreated. Other choices are incorrect because B may provide temporary relief but does not address the underlying concern, C should not be done without confirming the diagnosis, and D focuses on fluid intake and sodium intake but does not address the need to assess for preeclampsia.