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A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during this stage?
- A. coach the person through controlled pushing
- B. assist with spontaneous pushing
- C. assist with deep breathing
- D. offer non-pharmacological pain relief
Correct Answer: B
Rationale: The correct answer is B because in the second stage of labor, it is appropriate to assist the laboring person with spontaneous pushing to facilitate the descent of the baby through the birth canal. Controlled pushing (choice A) may cause fatigue and unnecessary strain. Deep breathing (choice C) is more suitable for the first stage of labor. Non-pharmacological pain relief (choice D) can be helpful but is not the priority in the second stage when the focus should be on pushing effectively.
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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.
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.
During open glottis pushing, what is the laboring person instructed to do?
- A. hold their breath and push for 10 seconds during each contraction
- B. push spontaneously while exhaling during contractions
- C. exhale slowly during contractions without pushing
- D. perform deep breathing exercises between contractions
Correct Answer: B
Rationale: During open glottis pushing, the correct instruction is for the laboring person to push spontaneously while exhaling during contractions (Choice B). This technique helps prevent breath-holding, which can increase intra-abdominal pressure and reduce blood flow to the heart and baby. Exhaling while pushing allows for better oxygenation and reduces the risk of Valsalva maneuver-related complications. Holding their breath (Choice A) can increase the risk of fetal distress. Exhaling slowly without pushing (Choice C) is not effective in assisting with the pushing stage of labor. Deep breathing exercises between contractions (Choice D) are beneficial for relaxation but not the main focus during pushing.
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.
A pregnant patient is 36 weeks gestation and reports increased vaginal discharge. What is the nurse's priority action?
- A. Assess the nature of the discharge for signs of infection.
- B. Instruct the patient to monitor the discharge at home.
- C. Recommend the patient use panty liners to manage the discharge.
- D. Provide education about normal pregnancy changes, including discharge.
Correct Answer: A
Rationale: The correct answer is A: Assess the nature of the discharge for signs of infection. At 36 weeks gestation, increased vaginal discharge could be a sign of infection, such as bacterial vaginosis or yeast infection, which can lead to preterm labor. The nurse's priority is to assess for infection to prevent any potential harm to the mother and baby. By assessing the nature of the discharge, the nurse can determine if further evaluation or treatment is needed.
Choice B is incorrect because instructing the patient to monitor the discharge at home does not address the potential seriousness of the situation. Choice C is incorrect as using panty liners only manages the symptom without addressing the underlying cause. Choice D is incorrect because providing education about normal pregnancy changes does not address the immediate need to rule out infection in this scenario.